Compendium Equine | July 2009 by davidpsu

3 CE Contact Hours | CompendiumEquine.com | Peer Reviewed

Vol 4(6) July/August 2009

From the H Horseâ&#x20AC;&#x2122;s Mouth

SERIES

E Extraction of the First o Premolar Teeth Vestibular Disease:

Temporohyoid Osteoarthropathy Methicillin-Resistant Staphylococcus aureus Infection

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Hence, the need for a predictable sedative. DORMOSEDAN® (detomidine hydrochloride). Sedation and pain management in one. DORMOSEDAN is an alpha 2 (α2) adrenoceptor agonist that interrupts the nervous system to provide both sedation and analgesia. No drug combining is necessary. Administered IV or IM, DORMOSEDAN is safe at full label dose and allows f lexible dosing to regulate length and depth of sedation and analgesia. (Additional dosing prolongs not deepens sedation.) DORMOSEDAN. Innovation you’d expect from a leader in equine health. To learn more, contact your Pﬁzer representative or visit safeandpredictable.com.

As with other α2 agonists, bradycardia and partial AV and SA blocks can occur with decreased respiratory rates. Occasional reports of anaphylactic-like reactions have been observed. The use of epinephrine should be avoided since epinephrine may potentiate the effects of α2 agonists. Please see full prescribing information for more information. DORMOSEDAN is a registered trademark of Orion Corporation and is distributed by Pfizer Animal Health. ©2008 Pfizer Inc. All rights reserved. DOR08032

See Page 241 for Product Information Summary

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Pfizer_Dormosedan_LEGAL.qxp:Sound Technologies_USE

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Sedative and Analgesic For Use in Horses Only Sterile Solution 10 mg/mL CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: Dormosedan® is a synthetic alpha-2 adrenoreceptor agonist with sedative and analgesic properties. The chemical name is 1H imidazole, 4-[(2,3-dimethylphenyl) methyl]-hydrochloride and the generic name is detomidine hydrochloride. It is a white, crystalline,water-soluble substance having a molecular weight of 222.7. The molecular formula is C12H14N2•HCl. CHEMICAL STRUCTURE:

Each mL of Dormosedan® contains 10.0 mg detomidine hydrochloride, 1.0 mg methyl paraben,5.9 mg sodium chloride, and water for injection, q.s. CLINICAL PHARMACOLOGY: Dormosedan®, a non-narcotic sedative and analgesic, is a potent _2 -adrenoreceptor agonist which produces sedation and superficial and visceral analgesia which is dose dependent in its depth and duration. Profound lethargy and a characteristic lowering of the head with reduced sensitivity to environmental stimuli (sounds, etc.) are seen with detomidine. A short period of incoordination is characteristically followed by immobility and a firm stance with front legs well spread. The analgesic effect is most readily seen as an increase in the pain threshold at the body surface. Sensitivity to touch is little affected and in some cases may actually be enhanced. With detomidine administration, heart rate is markedly decreased, blood pressure is initially elevated, and then a steady decline to normal is seen. A transient change in the conductivity of the cardiac muscle may occur, as evidenced by partial atrioventricular (AV) and sinoauricular(SA) blocks. This change in the conductivity of the cardiac muscle may be prevented by IV administration of atropine at 0.02 mg/kg of body weight. No effect on blood clotting time or other hematological parameters was encountered at dosages of 20 or 40 mcg/kg of body weight. Respiratory responses include an initial slowing of respiration within a few seconds to 1–2 minutes after administration, increasing to normal within 5 minutes. An initial decrease in tidal volume is followed by an increase. INDICATIONS: Dormosedan® is indicated for use as a sedative and analgesic to facilitateminor surgical and diagnostic procedures in mature horses and yearlings. It has been used successfully for the following: to calm fractious horses, to provide relief from abdominal pain, to facilitate bronchoscopy, bronchoalveolar lavage, nasogastric intubation, non reproductive rectal palpations, suturing of skin lacerations, and castrations. Additionally, an approved, local infiltration anesthetic is indicated for castration. CONTRAINDICATIONS: Dormosedan® should not be used in horses with pre-existing AV or SA block, with severe coronary insufficiency, cerebrovascular disease, respiratory disease, or chronic renal failure. Intravenous potentiated sulfonamides should not be used in anesthetized or sedated horses as potentially fatal dysrhythmias may occur. Information on the possible effects of detomidine hydrochloride in breeding horses is limited to uncontrolled clinical reports; therefore, this drug is not recommended for use in breeding animals. WARNINGS: Not for use in horses intended for food. Not for human use. Keep out of reach of children. HUMAN SAFETY INFORMATION: Care should be taken to assure that detomidine hydrochloride is not inadvertently ingested as safety studies have indicated that the drug is well absorbed when administered orally. Standard ocular irritation tests in rabbits using the proposed market formulation have shown detomidine hydrochloride to be nonirritating to eyes. Primary dermal irritation tests in guinea pigs using up to 5 times the proposed market concentration of detomidine hydrochloride on intact and abraded skin have demonstrated that the drug is nonirritating to skin and is apparently poorly absorbed dermally. However, in accordance with prudent clinical procedures, exposure of eyes or skin should be avoided and affected areas should be washed immediately if exposure does occur. As with all injectable drugs causing profound physiological effects, routine precautions should be employed by practitioners when handlingand using loaded syringes to prevent accidental self-injection.

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PRECAUTIONS: Before administration, careful consideration should be given to administering Dormosedan® to horses approaching or in endotoxic or traumatic shock, to horses withadvanced liver or kidney disease, or to horses under stress from extreme heat, cold, fatigue, or high altitude. Protect treated horses from temperature extremes. Some horses, although apparently deeply sedated, may still respond to external stimuli. Routine safety measures should be employed to protect practitioners and handlers. Allowing the horse to stand quietly for 5 minutes before administration and for 10–15 minutes after injection may improve the response to Dormosedan®. Dormosedan® is a potent _2-agonist, and extreme caution should be exercised in its use with other sedative or analgesic drugs for they may produce additive effects. When using any analgesic to help alleviate abdominal pain, a complete physical examination and diagnostic work-up are necessary to determine the etiology of the pain. Food and water should be withheld until the sedative effect of Dormosedan® has worn off. ADVERSE REACTIONS: Occasional reports of anaphylactic-like reactions have been received, including 1 or more of the following: urticaria, skin plaques, dyspnea, edema of the upper airways, trembling, recumbency, and death. The use of epinephrine should be avoided sinceepinephrine may potentiate the effects of _2 - agonists. Reports of mild adverse reactions haveresolved uneventfully without treatment. Severe adverse reactions should be treated symptomatically. As with all _2 -agonists, the potential for isolated cases of hypersensitivity exist,including paradoxical response (excitation). SIDE EFFECTS: Horses treated with Dormosedan® exhibit hypertension. Bradycardia routinely occurs 1 minute after injection. The relationship between hypertension and bradycardia is consistent with an adaptive baroreceptor response to the increased pressure and inconsistent with a primary drug-induced bradycardia. Piloerection, sweating, salivation, and slight muscle tremors are frequently seen after administration. Partial transient penis prolapse may be seen.Partial AV and SA blocks may occur with decreased heart and respiratory rates. Urination typically occurs during recovery at about 45–60 minutes posttreatment, depending on dosage. Incoordination or staggering is usually seen only during the first 3–5 minutes after injection,until animals have secured a firm footing. Because of continued lowering of the head during sedation, mucus discharges from the nose and, occasionally, edema of the head and face may be seen. Holding the head in a slightly elevated position generally prevents these effects. OVERDOSAGE: Detomidine hydrochloride is tolerated in horses at up to 200 mcg/kg of bodyweight (10 times the low dosage and 5 times the high dosage). In safety studies in horses,detomidine hydrochloride at 400 mcg/kg of body weight administered daily for 3 consecutive days produced microscopic foci of myocardial necrosis in 1 of 8 horses. DOSAGE AND ADMINISTRATION: For Sedation: Administer Dormosedan® IV or IM at the rates of 20 or 40 mcg detomidine hydrochloride per kg of body weight (0.2 or 0.4 mL of Dormosedan® per 100 kg or 220 lb), depending on the depth and duration of sedation required. Onset of sedative effects should be reached within 2–4 minutes after IV administration and 3–5 minutes after IM administration.Twenty mcg/kg will provide 30–90 minutes of sedation and 40 mcg/kg will provide approximately 90 minutes to 2 hours of sedation. For Analgesia: Administer Dormosedan® IV at the rates of 20 or 40 mcg detomidine hydrocloride per kg of body weight (0.2 or 0.4 mL of Dormosedan® per 100 kg or 220 lb), depending on the depth and duration of analgesia required. Twenty mcg/kg will usually begin to take effect in 2–4 minutes and provide 30–45 minutes of analgesia. The 40 mcg/kg dose will alsobegin to take effect in 2–4 minutes and provide 45–75 minutes of analgesia. For Both Sedation and Analgesia: Administer Dormosedan® IV at the rates of 20 or 40 mcg detomidine hydrochloride per kg of body weight (0.2 or 0.4 mL of Dormosedan® per 100 kg or 220 lb), depending on the depth and duration of sedation and analgesia required. Before and after injection, the animal should be allowed to rest quietly. STORAGE: Store at controlled room temperature 15°–30°C (59°–86°F) in the absence of light. HOW SUPPLIED: Dormosedan® is supplied in 5- and 20-mL multidose vials. U.S. Patent Nos. 4,443,466 and 4,584,383 NADA #140-862, Approved by FDA Manufactured by: Distributed by:

Animal Health Exton, PA 19341, USA Div. of Pfizer Inc NY, NY 10017

107224US-8 Made in Finland

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July/ August 2009 Vol 4(6) CompendiumEquine.com | Peer Reviewed | Free CE

The AAEP’s Media Partnership Program is composed of an esteemed group of industry-leading media outlets dedicated to providing resources and education, through the AAEP, to veterinarians and horse owners to improve the health and welfare of horses. Mission Statement: Compendium Equine is dedicated to providing essential and accurate clinical and professional information to beneﬁt equine practitioners, their profession, and their patients. Compendium Equine: Continuing Education for Veterinarians is free to veterinarians practicing in the United States. To sign up, go online to CompendiumEquine.com or call 800-426-9119, option 2. US subscriptions: $35 for 1 year. International subscriptions: Canadian and Mexican subscriptions (surface mail): $40 for 1 year. Other foreign subscriptions (surface mail): $135 for 1 year. Payments by check must be in US funds drawn on a US branch of a US bank only; credit cards are also accepted. Change of Address: Please notify the Circulation Department 45 days before the change is to be effective. Send your new address and enclose an address label from a recent issue. Selected back issues are available for $8 (United States and Canada) and $10 (foreign) each (plus postage).

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Compendium Equine

EXECUTIVE EDITOR Tracey L. Giannouris, MA 800-426-9119, ext 52447 | tgiannouris@vetlearn.com

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MANAGING EDITOR Kirk McKay 800-426-9119, ext 52434 | kmckay@vetlearn.com SENIOR EDITOR Robin A. Henry 800-426-9119, ext 52412 | rhenry@vetlearn.com ASSOCIATE EDITOR Chris Reilly 800-426-9119, ext 52483 | creilly@vetlearn.com ASSISTANT EDITOR Benjamin Hollis 800-426-9119, ext 52489 | bhollis@vetlearn.com VETERINARY ADVISERS Dorothy Normile, VMD, Chief Medical Officer 800-426-9119, ext 52442 | dnormile@vetlearn.com Amy I. Bentz, VMD, DACVIM, Professional Services Manager 800-426-9119, ext 52389 | abentz@vetlearn.com SENIOR ART DIRECTOR Michelle Taylor 267-685-2474 | mtaylor@vetlearn.com ART DIRECTOR David Beagin 267-685-2461 | dbeagin@vetlearn.com OPERATIONS Marissa DiCindio, Director of Operations 267-685-2405 | mdicindio@vetlearn.com Elizabeth Ward, Production Manager 267-685-2458 | eward@vetlearn.com Christine Polcino, Trafﬁc Manager 267-685-2419 | cpolcino@vetlearn.com SALES & MARKETING Joanne Carson, National Account Manager 267-685-2410 | Cell 609-238-6147 | jcarson@vetlearn.com Boyd Shearon, Account Manager 913-322-1643 | Cell 215-287-7871 | bshearon@vetlearn.com Lisa Siebert, Account Manager 913-422-3974 | Cell 215-589-9457 | lsiebert@vetlearn.com CLASSIFIED ADVERTISING Classified Advertising Specialist Fax 201-231-6373 | classifieds@vetlearn.com EXECUTIVE OFFICER Derrick Kraemer, President CUSTOMER SERVICE 800-426-9119, option 2 | info.vls@medimedia.com

Published nine times per year by Veterinary Learning Systems, a division of MediMedia, 780 Township Line Road, Yardley, PA 19067. Copyright © 2009 Veterinary Learning Systems. All rights reserved. Printed in the USA. No part of this issue may be reproduced in any form by any means without prior written permission of the publisher. Compendium Equine: Continuing Education for Veterinarians (ISSN 15595811) is published nine times per year by Veterinary Learning Systems, 780 Township Line Road, Yardley, PA 19067. Periodicals postage paid at Morrisville, PA 19067-9998, and additional mailing ofﬁces. POSTMASTER: Send address changes to Compendium Equine, 780 Township Line Road, Yardley, PA 19067.

Compendium Equine: Continuing Education for Veterinarians® (ISSN 1559-5811)

July/ August 2009 Vol 4(6) CompendiumEquine.com | Peer Reviewed | Free CE

EDITORIAL BOARD Michelle Henry Barton, DVM, PhD, DACVIM The University of Georgia Internal Medicine

EDITOR IN CHIEF James N. Moore, DVM, PhD Department of Large Animal Medicine College of Veterinary Medicine The University of Georgia Athens, GA 30602 706-542-3325 Fax 706-542-8833 jmoore@uga.edu

Gary M. Baxter, VMD, MS, DACVS Colorado State University Acupuncture, Surgery Jim Belknap, DVM, PhD, DACVS The Ohio State University Soft Tissue Surgery Bo Brock, DVM, DABVP (Equine) Brock Veterinary Clinic, Lamesa, Texas Surgery Noah D. Cohen, VMD, MPH, PhD, DACVIM (Internal Medicine) Texas A&M University Internal Medicine Norm G. Ducharme, DVM, MSc, DACVS Cornell University Large Animal

Compendium Equine is a refereed journal. Articles published herein have been reviewed by at least two academic experts on the respective topic and by the editor in chief.

Raymond J. Geor, BVSc, MVSc, PhD, DACVIM Michigan State University Metabolism, Nutrition, Endocrine-Related Laminitis Katharina Lohmann, MedVet, PhD, DACVIM (Large Animal) University of Saskatchewan Large Animal Robert J. MacKay, BVSc, PhD, DACVIM (Large Animal) University of Florida Large Animal Rustin M. Moore, DVM, PhD, DACVS The Ohio State University Surgery Debra Deem Morris, DVM, MS, DACVIM East Hanover, New Jersey Internal Medicine P. O. Eric Mueller, DVM, PhD, DACVS The University of Georgia Soft Tissue and Orthopedic Surgery

Susan C. Eades, DVM, PhD, DACVIM (Large Animal) Louisiana State University Large Animal

Elizabeth M. Santschi, DVM, DACVS The Ohio State University Surgery

Earl M. Gaughan, DVM, DACVS Littleton Large Animal Clinic Littleton, Colorado Surgery

Nathaniel A. White II, DVM, MS, DACVS Virginia Polytechnic Institute and State University Surgery

Any statements, claims, or product endorsements made in Compendium Equine are solely the opinions of our authors and advertisers and do not necessarily reï¬&#x201A;ect the views of the Publisher or Editorial Board.

CompendiumEquine

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July/August 2009 Vol 4(6)

Features 254 FREE

❯❯ Cleet Grifﬁn The extraction procedures described in this article are straightforward and can yield successful outcomes. Learn how to manage complications as well.

CompendiumEquine.com | Peer Reviewed | Free CE

Each CE article is accredited for 3 contact hours by Auburn University College of Veterinary Medicine.

From the Horse’s Mouth Extraction of the First NEW SERIES Premolar Teeth

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Fare Thee Well: How to Help Owners (and Yourself) Deal With the Death of a Horse ❯❯ Amy I. Bentz and Christina Bach This article addresses the issues that equine practitioners commonly face when interacting with owners before and after their horses have been euthanized.

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Therapeutics in Practice Treating Methicillin-Resistant Staphylococcus aureus Infection ❯❯ J. Scott Weese Learn how to manage this often-treatable, emerging problem in equine medicine.

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Vestibular Disease: Temporohyoid Osteoarthropathy ❯❯ Bonnie R. Rush and Jason A. Grady This overview of a common cause of vestibular disease in horses is presented in a quick-reference format, including diagnosis, treatment, and prognosis.

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Abstract Thoughts Inﬂammation and Male Infertility: A Break in Immune Privilege Affects “Mojo” ❯❯ David J. Hurley and James N. Moore There is growing evidence that local inﬂammatory and immune responses to infection and tissue damage occur in the testes as they do in other body tissues.

Departments 246 CompendiumEquine.com

286 Product Forum

248 The Editor’s Desk: Your Journal, Your Success

287 Index to Advertisers

❯❯ Kirk McKay

2499

Calendar

250 Clinical Snapshot Recurrent Epistaxis in a Thoroughbred Mare ❯❯ Adam Stern

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Compendium Equine: Continuing Education for Veterinarians®

287 Classiﬁed Advertising 288 The Final Diagnosis Through the Eyes, and Ears, of a Child ❯❯ Bo Brock Clinical Snapshot

PAGE 250

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Federal law restricts this drug to use by or on the order of a licensed veterinarian. For use in horses only. Do not use in horses intended for food.

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4/29/09 4:19:51 PM

Scale

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Trim Size:

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Color: 4C Pantone Colors:

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B:11”

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So choose the only FDA-approved I.V. joint therapy for equine noninfectious synovitis.

T:10.75”

Both depend on which therapy you choose.

WEB EXCLUSIVES

July/ August

2009 Vol 4(6) CE ARTICLES E-NEWSLETTERS

Earn 3 free contact hours for each CE article. SEARCHABLE ARCHIVES

Search all content since Compendium Equine’s launch in 2005.

WEB-EXCLUSIVE VIDEOS

❯❯ Head Shaking Videos Head shaking is one of the most difﬁcult problems to diagnose because of the great diversity of causes. Watch videos of typical and photic head shaking.

CE CONFERENCE CALENDAR

❯❯ EquineMail helps you prepare for questions from your clients by highlighting the latest topics from popularr publications for horse owners. In addition, links to related content in Compendium Equine are provided.

❯❯ Compendium Equine EXTRA provides a preview of, and access to, the latest issue of Compendium Equine. Breaking news and Web-exclusive content are included. For both monthly e-news-letters, sign up for free at CompendiumEquine.com

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Check the online version to ﬁnd events that aren’t listed in the journal. NEWS BITS

❯❯ Veterinarians at High Risk for Viral and Bacterial Infections ❯❯ AAEP Issues Recommendations for Purchase Exams at Public Auctions

❯❯ E-mail your questions, suggestions, comments, or letters to the editor: editor@CompendiumEquine.com

We’re for saving lives.

NEW EquiRab™ the first rabies vaccine designed specifically for the horse. We’re for recommending rabies protection for every horse, every year. For following the AAEP core vaccine guidelines. For preventing a fatal disease and your exposure to it. With low reaction rates and a 14-month DOI, EquiRab is the only rabies vaccine made specifically for the horse. Recommend EquiRab to your clients. Because like you, we’re for not taking chances with a horse’s life.

We’re for the horse. P.O. Box 318 • 29160 Intervet Lane • Millsboro, Delaware 19966 • intervetusa.com • 800.521.5767 EquiRab is a trademark of Intervet Inc. or an affiliate. ©2008 Intervet Inc. All rights reserved. 35961-EquiRabVet-05/09-FP4C-CE

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www.equirab.com

2/11/09 10:17:00 AM

The Editor’s Desk ❯❯ Kirk McKay, Managing Editor

Your Journal, Your Success

ompendium Equine* is your journal: equine practitioners provide the content, peer review it, read it, apply it to practice, and evaluate it in surveys. So congratulations! You deserve much of the credit for making this journal a favorite among equine practitioners. In only 3 years after its launch, Compendium Equine has the highest percentage of average issue readers and is rated highest in usefulness by its readers compared with ratings for other publications by their readers.1 In addition, the journal’s circulation has grown to 16,181.2 See the BOX for other highlights. I believe the journal’s success is reﬂective of the strength of the equine veterinary profession and the equine industry. Compendium Equine’s staff and editorial board know you’ve been essential to the success of the journal and, in turn, want it to be an important resource for your professional success. Our mission is clear: Compendium Equine is dedicated to providing essential and accurate clinical and

Highlights in Compendium Equine’s History Spring 2006: Compendium Equine is launched! August 2007: The journal becomes an AAEP Media Partner—one of an esteemed group of industry-leading media outlets dedicated to providing resources and education, through the AAEP, to veterinarians and horse owners to improve the health and welfare of horses. March 2008: EquineMail, a monthly e-newsletter, is launched to help you prepare for client questions regarding equine health care news in horse owner–oriented publications such as Equus, Practical Horseman, and Horse & Rider. June 2008: The journal begins offering free CE. November 2008: The journal begins offering 3 (rather than 2) CE credits per article. January 2009: The journal’s redesign is unveiled. March 2009: Equine Extra, a monthly e-newsletter, is launched to give you breaking news, Web-exclusive content, and a preview of the upcoming issue of the journal.

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professional information to benefit equine practitioners, their profession, and their patients. We’ll continue to fulfill this mission through the journal’s various targeted features. Last year’s launch of “Imaging Is Believing” (diagnostic imaging series) and this year’s launches of “From the Horse’s Mouth” (dentistry series) and “Cutting to Cure” (surgery series) have been well received. And the highly anticipated “Feed Stuff” nutrition series is on the way. This issue delivers the following important features: “Extraction of the First Premolar Teeth” (a follow-up to “The First Premolar Teeth” in the March 2009 issue), “Treating MethicillinResistant Staphylococcus aureus Infection,” “Fare Thee Well: How to Help Owners (and Yourself) Deal with the Death of a Horse,” and “Vestibular Disease: Temporohyoid Osteoarthropathy.” It’s a pleasure working with equine practitioners to produce Compendium Equine and its associated media: the EquineMail and Equine Extra monthly e-newsletters and CompendiumEquine. com, which includes CE content (also available at CECenter.com), Web-exclusive news and videos, and a searchable archive of the journal’s content. And knowing that we’re helping you with your equine patients and clients is always inspiring. I encourage you to think of Compendium Equine as your journal and to recognize the connection between the journal’s success and your success. Thank you for all you’ve done to make the journal a favorite among equine practitioners. As always, we welcome your comments and suggestions, so don’t hesitate to e-mail (kmckay@ vetlearn.com) or call (800-426-9119, ext 52434) me. In addition, I would be happy to talk to you about the various ways to contribute content to your journal. Enjoy the rest of your summer! *Published by Veterinary Learning Systems (VLS; VetLearn. com), Yardley, Pennsylvania. References 1. PERQ/HCI FOCUS® Veterinary 2009 Data. Tables 104 and 202 Equine. 2. December 2008 BPA statement. Total qualified circulation.

Compendium Equine: Continuing Education for Veterinarians® | July/August 2009 | CompendiumEquine.com

CE Calendar August 5–7 4th World Equine Airways Symposium University of Berne Berne, Switzerland Web www.weas09.unibe.ch

August 6 3rd Annual Hambletonian Continuing Education Wet Labs for Equine Veterinarians Meadowlands Racetrack East Rutherford, New Jersey Phone 973-240-7471 E-mail gordon@ﬁrstchoicemarketing Web www.ﬁrstchoicemarketing.us

August 7 4th Annual Hambletonian Continuing Education Wet Labs for Equine Veterinarians Meadowlands Racetrack East Rutherford, New Jersey Phone 973-240-7471 E-mail gordon@ﬁrstchoicemarketing Web www.ﬁrstchoicemarketing.us

Only Adequan® i.m. (polysulfated glycosaminoglycan)

August 7–8 Florida Association of Equine Practitioners 2nd Annual Promoting Excellence Foot/Farrier Symposium Orlando, Florida Web www.faep.net

stimulates cartilage repair and reverses traumatic joint dysfunction

Within 48 hours the hyaluronic acid (HA) in the synovial fluid nearly doubles after a single injection.* Recommended dose: 5 mL every 4 days for 7 treatments intramuscularly.

August 26–30 Focus on the Equine Spine: Thoracolumbar Region Colorado State University College of Veterinary Medicine Phone 970-297-1273 E-mail tiffany.banﬁeld@colostate.edu

August 27–30 Veterinary Thermal Imaging Seminar

To learn about the wear-and-repair of joints go to www.adequan.com. Or call 800-974-9247 for a free video.

The Ohio State University Phone 800-458-8890 Web veteldiagnostics.com

August 27–30 Equine Thermography Conference The Ohio State University College of Veterinary Medicine Columbus, Ohio Phone 614-292-8727 E-mail vetmedce@osu.edu Web https://vetmedce.osu.edu Compiled by Benjamin Hollis; send listings to bhollis@vetlearn.com. CompendiumEquine | July/August 2009

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Keep joints in healthy balance There are no known contraindications to the use of intramuscular PSGAG in horses. Studies have not been conducted to establish safety in breeding horses. WARNING: Do not use in horses intended for human consumption. Adequan® i.m. brand Polysulfated Glycosaminoglycan (PSGAG). Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Each 5 mL contains 500 mg Polysulfated Glycosaminoglycan. Brief Summary Indications: For the intramuscular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal and hock joints in horses. LUITPOLD PHARMACEUTICALS, INC. Animal Health Division, Shirley, NY 11967. See product package insert for full prescribing information. *Burba DJ, Collier MA, Default LE, Hanson-Painton O, Thompson HC, Holder CL: IN VIVO KINETIC STUDY ON UPTAKE AND DISTRIBUTION OF INTRAMUSCULAR TRITIUM-LABELED POLYSULFATED GLYCOSAMINOGLYCAN IN EQUINE BODY FLUID COMPARTMENTS AND ARTICULAR CARTILAGE IN AN OSTEOCHONDRAL DEFECT MODEL. The Journal of Equine Veterinary Science 1993; 696-703. Concentrations of Adequan i.m. in the synovial fluid begin to decline after peak levels are reached at 2 hours; then remain constant from 24 hours post injection through 96 hours. © 2008 Luitpold Animal Health. Adequan® is a registered trademark of Luitpold Pharmaceuticals, Inc. AHD 85201, Iss. 2/08 CE

Clinical Snapshot Case Presentation #1

❯❯ Adam Stern, DVM Oklahoma State University

A 13-year-old Thoroughbred mare presented to the Oklahoma State University College of Veterinary Medicine with a history of mild, recurrent epistaxis. On physical examination, a large mass was noted arising from the nasal mucosa in the cranial aspect of the right nasal cavity. There was a small amount of mucopurulent discharge in the affected nostril. No other clinical abnormalities were noted on examination. The mass was completely removed by excisional biopsy. The histopathologic appearance of the nasal mass is shown (A; hematoxylin–eosin stain; magniﬁcation: ×100). 1. What is your diagnosis? 2. In what regions of the world is this

disease most likely to occur? SEE PAGE 252 FOR ANSWERS AND EXPLANATIONS.

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10/3/08 3:03:30 PM

Clinical Snapshot

EQUIOXX® (firocoxib) Oral Paste for Horses Non-steroidal anti-inflammatory drug for oral use in horses only. CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian.

Answers and Explanations Case Presentation #1

Indications: EQUIOXX® Oral Paste is administered for up to 14 days for the control of pain and inflammation associated with osteoarthritis in horses. Contraindications: Horses with hypersensitivity to firocoxib or other NSAIDs should not receive EQUIOXX® Oral Paste. Warnings: For oral use in horses only. Do not use in horses intended for human consumption. Human Warnings: Not for use in humans. Keep this and all medications out of the reach of children. Consult a physician in case of accidental ingestion by humans. Animal Safety: Client should be advised to observe for signs of potential drug toxicity and be given a Client Information Sheet with each prescription. For technical assistance or to report suspected adverse events, call 1-877-217-3543. Precautions: Horses should undergo a thorough history and physical examination before initiation of NSAID therapy. Appropriate laboratory tests should be conducted to establish hematological and serum biochemical baseline data before and periodically during administration of any NSAID. Clients should be advised to observe for signs of potential drug toxicity and be given a Client Information Sheet with each prescription. See Information for Owner or Person Treating Horse section of this package insert. Treatment with EQUIOXX® should be terminated if signs such as inappetence, colic, abnormal feces, or lethargy are observed. As a class, cyclooxygenase inhibitory NSAIDs may be associated with renal and gastrointestinal toxicity. Sensitivity to drug-associated adverse events varies with the individual patient. Patients at greatest risk for adverse events are those that are dehydrated, on diuretic therapy, or those with existing renal, cardiovascular, and/or hepatic dysfunction. Concurrent administration of potentially nephrotoxic drugs should be carefully approached or avoided. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Since many NSAIDs possess the potential to produce gastrointestinal ulcerations, concomitant use with other antiinflammatory drugs, such as NSAIDs or corticosteroids, should be avoided or closely monitored. The concomitant use of protein bound drugs with EQUIOXX® Oral Paste has not been studied in horses. The influence of concomitant drugs that may inhibit the metabolism of EQUIOXX® Oral Paste has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy.

SEE PAGE 250 FOR CASE PRESENTATION.

1. Based on histopathologic evaluation

of the lesion, a diagnosis of proliferative, granulomatous rhinitis with trophocytes (B; T; hematoxylin– eosin stain; magnification: ×200) was made. The morphology of the trophocytes is most consistent with Rhinosporidium seeberi. 2. Rhinosporidiosis, a disease of humans and dogs, rarely affects other domestic animal species such as horses. The disease is endemic in tropical and wet environments such as the

Indian subcontinent and Argentina1 and is far less common in North America, where most reported cases occur in the southern United States. Surgical excision as performed in this case is considered curative. The mare in this case was unavailable for follow-up. Reference 1. Lupi O, Tyring SK, McGinnis MR. Tropical dermatology: fungal tropical diseases. J Am Acad Dermatol 2005;53:931-951.

The safe use of EQUIOXX® Oral Paste in horses less than one year in age, horses used for breeding, or in pregnant or lactating mares has not been evaluated. Consider appropriate washout times when switching from one NSAID to another NSAID or corticosteroid. Adverse Reactions: In controlled field studies, 127 horses (ages 3 to 37 years) were evaluated for safety when given EQUIOXX® Oral Paste at a dose of 0.045 mg/lb (0.1 mg/kg) orally once daily for up to 14 days. The following adverse reactions were observed. Horses may have experienced more than one of the observed adverse reactions during the study. Adverse Reactions Seen In U.S. Field Studies

Adverse Reactions

EQUIOXX n=127

Active Control n=125

Abdominal pain

Diarrhea

Excitation

Lethargy

Loose stool

Polydipsia

Urticaria

EQUIOXX® (firocoxib) Oral Paste was safely used concomitantly with other therapies, including vaccines, anthelmintics, and antibiotics, during the field studies. Information for Owner or Person Treating Horse: You should give the Client Information Sheet to the person treating the horse and advise them of the potential for adverse reactions and the clinical signs associated with NSAID intolerance. Adverse reactions may include erosions and ulcers of the gums, tongue, lips and face, weight loss, colic, diarrhea, or icterus. Serious adverse reactions associated with this drug class can occur without warning and, in rare situations, result in death. Clients should be advised to discontinue NSAID therapy and contact their veterinarian immediately if any of these signs of intolerance are observed. The majority of patients with drug-related adverse reactions recover when the signs are recognized, drug administration is stopped, and veterinary care is initiated. Storage Information: Store below 86°F (30°C). Brief excursions up to 104°F (40°C) are permitted. How Supplied: EQUIOXX is available in packs of 20, 72 and 216 individually-boxed syringes. Each syringe contains 6.93 grams of EQUIOXX® paste, sufficient to treat a 1250 lb. horse. For technical assistance or to report suspected adverse reactions, call 1-877-217-3543.

T = trophocytes.

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NADA 141-253, Approved by FDA EQUIOXX is a registered trademark of Merial Limited, Duluth, Georgia, USA. ® 1050-2012-01 Rev. 02-06 Copyright© 2006 Merial Limited. All Rights Reserved. U.S. Pat. No.: 5981576, 6020343

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There’s a new movement in equine pain management.

Osteoarthritis pain relief with staying power.2 EQUIOXX®(firocoxib). EQUIOXX® (firocoxib) is the next generation of pain management. It is the first and only coxib NSAID approved for horses and provides 24 hours of prescription pain relief* in just one daily dose.2 It’s also the only NSAID approved for use up to 14 consecutive days by the AQHA3 and the USEF4 — compared with only five days for other traditional NSAIDs.3,4 The efficacy and safety of EQUIOXX have been more thoroughly tested than any other equine NSAID on the market.5,6 You can be part of this new movement — and the source for osteoarthritis pain relief with staying power. Help your practice and your clients by offering EQUIOXX. For details visit www.equioxx.com.

As with any prescription medication, prior to use, a veterinarian should perform a physical examination and review the horse’s medical history. A veterinarian should advise horse owners to observe for signs of potential drug toxicity. As a class, nonsteroidal anti-inflammatory drugs may be associated with gastrointestinal and renal toxicity. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. EQUIOXX has not been tested in horses less than 1 year of age or in breeding horses, or pregnant or lactating mares. For additional information please refer to the prescribing information or visit www.equioxx.com. *Joint pain and inflammation associated with equine osteoarthritis, also called degenerative joint disease. 1 Data on file at Merial. 2 EQUIOXX product label. 3 American Quarter Horse Association. Show rules and regulations. Official Handbook of Rules and Regulations 2008:128. 4 United States Equestrian Federation. Drugs and medications guidelines. 2007:2-3. Available at: http://www.usef.org/documents/competitions/2007/2007DrugsMedsGuidelines.pdf. Accessed February 20, 2009. 5 Based on data provided in FDA Freedom of Information summaries. 6 Data on file at Merial, Safety Study, PR&D 0030701. ®EQUIOXX is a registered trademark of Merial. ©2009 Merial Limited. Duluth, GA. All rights reserved. EQUIEQX924-A (06/09) See Page 252 for Product Information Summary

Official product of 3,4

3 CE CREDITS

CE Article 1

From the Horse’s Mouth features important topics on equine dentistry

NEW

Extraction of the First Premolar Teeth ❯❯ Cleet Grifﬁn, DVM, DABVP Texas A&M University

Abstract: In most cases, the small, functionless ﬁrst premolar teeth (wolf teeth) of horses cause no harm. However, in some riding horses, these teeth may be a source of discomfort. As a result, wolf teeth are often extracted by veterinarians. For success, the extraction procedure described in this article requires the veterinarian to be prepared with proper instrumentation and to proceed patiently; the patient must be adequately sedated and restrained and a local anesthetic administered before initiation of the extraction procedure. The use of a dental speculum during wolf tooth extraction can substantially improve visualization during the procedure.

At a Glance Extraction Procedures Page 254

Sedation and Local Anesthesia Page 255

Extraction of Erupted Wolf Teeth Page 255

Complications Page 260

Aftercare Page 262

*A companion article titled “The First Premolar Teeth” appeared in the March 2009 issue.

254

n most horses, the first premolar teeth (wolf teeth) are located just rostral to the first cheek teeth and commonly erupt in the first year of life. The number of wolf teeth in a horse can vary from none to four. The upper arcade is the most common location for eruption of these teeth, but they may be seen on the lower arcade as well. In most cases, these teeth are small and functionless and do not cause problems. However, wolf teeth may cause discomfort to some horses as a result of a bit placing pressure on a wolf tooth and the surrounding sensitive mucosal tissue. Unerupted wolf teeth (“blind” or “impacted” wolf teeth) may cause discomfort when the mucosa is compressed against the tooth by a bit. Wolf teeth in the lower arcade, whether erupted or unerupted, have been associated with bitting problems in horses. In addition, the presence of wolf teeth can make it difficult for veterinarians to adequately float and smooth the rostral part of the second premolar tooth (i.e., create a “bit seat”). For these reasons, wolf teeth are often extracted from young riding horses to prevent performance problems related to oral

discomfort. Older horses with a history of attitude change or unusual head action should also be examined for the presence of wolf teeth or remnants from a previous extraction.

Extraction Procedures Wolf teeth can be extracted during most routine dental procedures, such as a dental examination or ﬂotation. Several different instruments are available for these purposes, and techniques for extraction of wolf teeth have been described.1–8 Excessive chewing movements, vigorous tongue movement,1 and “rooting” behavior by the horse can be very frustrating for the veterinarian during attempts to extract wolf teeth. In addition, the size of the crown of a wolf tooth may be misleading as to the degree of difﬁculty that may be encountered during removal.4 Consequently, adequate restraint, sedation, and analgesia; good visualization; and proper instrumentation are key considerations to maximize the safety of the veterinarian and horse and to minimize the risk of complications associated with dental procedures.

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Extraction of the First Premolar Teeth CE Sedation and Local Anesthesia After the initial examination, the horse should be administered either detomidine (0.01 to 0.02 mg/kg IV) or xylazine (0.25 to 0.50 mg/ kg IV) to provide sedation. After 5 minutes, the mouth should be rinsed with water and the head supported at an appropriate height using either a dental halter or a head stand. A full-mouth dental speculum can be applied to provide optimal visualization during the procedure. A variety of speculums, including McPherson, Conrad, and Stubbs designs, can be used during extraction of wolf teeth. Local anesthesia is recommended before extraction of wolf teeth in order to provide an additional level of comfort for the horse and to reduce the amount of struggling, head tossing, chewing, and tongue movement during the procedure.1,7,8 With the mouth held open by the speculum, a needle is directed through the palatine mucosa toward the crease between the gingiva and palatine mucosa on the palatal side of the wolf tooth7,8 (FIGURE 1). Approximately 1.5 to 2 mL of mepivacaine hydrochloride solution (2%; Carbocaine-V, Pfizer Animal Health) is injected submucosally in this area, and the solution is allowed to diffuse into the gingiva around the tooth. Although the submucosa of the hard palate is shallow and fibrous, the anesthetic solution can be injected with firm pressure. A mucosal bleb will appear if the injection is performed properly. If necessary, an additional 1 to 2 mL of local anesthetic solution may be injected submucosally on the buccal side of the wolf tooth at the junction of the gingiva and cheek mucosa. For blind upper wolf teeth, mepivacaine solution is injected submucosally in the tissues overlying the buried crown. For mandibular wolf teeth, 1.5 to 2 mL of mepivacaine is injected through the loose fold of mucosa just rostral to the wolf tooth.

(Burgess instrument) is very useful for initially cutting the gingiva around the circumference of the tooth. The ring of incised gingiva that is created around the tooth by the Burgess instrument serves as a useful outline when a periodontal elevator is used. Burgess instruments can be designed to accommodate various-sized wolf teeth, and handle extension bars are also available (FIGURE 2). Instruments with these extension bars are needed when a speculum is in place during the extraction procedure. A gap of at least 2 to 3 mm must exist between the wolf tooth and the second premolar to properly place the Burgess instrument over the crown without dramatically increasing the risk of breaking the wolf tooth root when force is applied to the instrument. When a speculum is used, the Burgess instrument and periodontal elevator should be directed in the vertical axis over the tooth. This requires the veterinarian to pass the shaft of the Burgess instrument between the inner side of the cheek bars of the speculum and the horse’s face (FIGURES 3 AND 4). After cutting the gingiva, it is advisable not to further loosen the periodontal attachments with the Burgess instrument. With the gingival cut margin as a guide, the tip of a periodontal elevator is used to elevate the gingival tissue to a depth of several millimeters around the periphery of the tooth to loosen the soft

CriticalPo nt Adequate restraint, sedation, and analgesia; good visualization; and proper instrumentation are key considerations during extraction of wolf teeth.

FIGURE 1

Extraction of Erupted Wolf Teeth The steps for extracting an erupted wolf tooth include elevating the gingival tissue and periodontal attachments from the crown and root, removing the loosened tooth with forceps, and inspecting the alveolar margin for sharp or loose fragments. Several instruments may be used to complete each step (FIGURE 2). A few principles should be considered when deciding which instruments to use for a particular horse. An instrument with a circular tip

Deposition of local anesthetic into the palatine submucosa and gingiva adjacent to the wolf tooth (Triadan 205).

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FREE CE Extraction of the First Premolar Teeth

tissue attachments. After sufﬁciently elevating the gingiva on the rostral, buccal, and palatal sides of the tooth, the tip of the elevator can usually be placed between the wolf tooth and the ﬁrst cheek tooth to further elevate the wolf tooth (FIGURE 5). With the tip of the elevator in place, the shaft of the elevator may be slowly twisted or rocked slightly and held FIGURE 2

Instruments that can be used to assist with wolf tooth extraction include periodontal elevators of various sizes and lengths, a Burgess instrument with handle extensions and cutting cones (blue tape), a curette, a forceps, and a rubber mallet. FIGURE 3

Passing the instrument on the axial side of the lower cheek bar of the speculum allows a more vertical orientation within the patient’s mouth for extraction of upper wolf teeth.

256

for several seconds to apply pressure against the periodontal attachments of the wolf tooth root. These maneuvers should be done with patience because they slowly disrupt the soft tissue attachments to the root; the premature use of excessive force usually results in breakage of the tooth. Caution should be exercised not to damage the second premolar by applying excessive pressure with the elevator. With sufficient elevation of periodontal tissues and subsequent bleeding within the alveolus, the root usually becomes loose and the tooth can be grasped and removed with a wolf tooth forceps. Mandibular wolf teeth are removed in a similar manner. The close proximity of a lower wolf tooth to the second premolar usually prohibits the use of a Burgess instrument to cut the gingiva. A small, half-moon–shaped elevator is usually sufficient to elevate the gingival and periodontal tissues to allow extraction of lower wolf teeth. If an upper blind wolf tooth is identified, a Burgess instrument can be used to cut a circular area of gingiva overlying the crown; alternatively, a curved scalpel blade may be used to incise the mucosa over the length of the crown.7,8 A half-moon–shaped elevator or a periosteal elevator is then used to elevate the gingiva. The instrument is directed between the horizontally situated wolf tooth and the maxillary bone. Alternatively, a Burgess instrument may be slid over the crown of the tooth to continue elevating the tissues away from the tooth. In either case, firm, controlled efforts are used to wiggle and pry the soft tissue attachments away from the tooth root so that the tooth can be removed. Each tooth should be thoroughly inspected after removal. On occasion, the root of the tooth will fracture near its junction with the crown (FIGURE 6). If a pulp chamber is visible in the extracted tooth, Stelzer5 has advocated removal of the retained root tip with a root forceps. However, if the fractured root remnant is anchored well and does not protrude over the rim of the alveolus, the additional surgical trauma required for removal of the remnant is unnecessary.3,6,8 In my experience, leaving the remnant has not been associated with lasting harmful effects. Instead, the owner should be made aware of possible complications of a root tip fracture (e.g., irritation, redness, pain,

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FREE CE Extraction of the First Premolar Teeth

FIGURE 4

CriticalPo nt The steps for extracting a wolf tooth include elevating the gingival tissue and periodontal attachments from the crown and root, removing the loosened tooth with forceps, and inspecting the alveolar margin for sharp or loose fragments.

A circular-tip cutting instrument is placed over the wolf tooth (Triadan 105) to cut the gingiva around the periphery of the tooth. (Cadaver specimen.) FIGURE 5

Using the cut margin around the tooth as a guide, the clinician uses an elevator to loosen the attachments of the wolf tooth (Triadan 105). (Cadaver specimen.)

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FREE CE Extraction of the First Premolar Teeth

CriticalPo nt Soft tissue infections, sepsis, and tetanus have reportedly occurred after wolf tooth extraction. Therefore, it is wise to assess the patient’s vaccination history and administer tetanus prophylaxis, if indicated.

bitting problems, or a draining tract of the overlying gingival tissue due to migration of the fractured root tip). If any of these complications develop, radiography of the affected area is warranted, and any tooth remnants should be removed (using sedation and local anesthesia as previously described). After removal of a wolf tooth, a gloved fingertip should be used to palpate the extraction site for the presence of loose tooth fragments or sharp areas of bone on the rim of the alveolus. Loose root fragments may be removed with an elevator or a forceps, and any bony spicules and sharp areas created during the extraction should be smoothed with a curette or rongeur.6 Some wolf teeth can be very difficult to loosen, requiring the use of a slightly angled, flat-ended elevator to elevate the tissue on the rostral side of the tooth.a A rubber mallet is used to tap the handle of the elevator several times, and then the elevator is repositioned on the caudal side of the tooth; this process is repeated until the tooth is loosened sufficiently to be extracted. This technique elevates the gingiva and disrupts periodontal tissue around the wolf tooth.8 There are two important concerns when using this technique. First, it should not be used on the palatal side of the tooth because of the close proximity of the palatine artery. Second, gingival tissue on the buccal side of the tooth can easily be damaged with this technique; this tissue can usually be elevated sufficiently without the use of a mallet. In my experience, this technique has facilitated removal of a number of diffia

Scrutchﬁeld WL. Personal communication, College Station, Texas, May 2007.

FIGURE 6

cult wolf teeth without complication, but it is always used judiciously. The occasional use of a mallet and elevator to assist removal of large wolf teeth in Draft breeds has been described previously,2 and general anesthesia has been reported to be necessary in some instances to assist in removing molarized wolf teeth.7

Complications Excessive Hemorrhage The major palatine artery, originating from a branch of the maxillary artery, runs cranially along the palatine groove from the major palatine foramen (located near the caudal border of the hard palate) and is accompanied by a vein and nerve. The palatine groove is parallel to, and within about one ﬁnger-width of, the upper cheek teeth.5 Along its course, the major palatine artery provides branches supplying the hard palate and the mucosa of the ﬂoor of the ventral nasal meatus. Near the corner incisors (Triadan 103 and Triadan 203), the artery curves medially to unite with the artery from the opposite side and passes through the incisive foramen9,10 (FIGURE 7). The artery may be inadvertently cut during elevation of wolf teeth, resulting in sudden, copious hemorrhage originating from the surgical wound in the mucosa of the hard palate. If this occurs, the horse’s head should be elevated (to about the level of the withers) and direct pressure applied to the hemorrhaging vessel using a stack of 4 × 4–inch gauze sponges. The gauze compress is then temporarily secured in the roof of the mouth with elastic tape around the muzzle. The compress is left in place until hemorrhage is controlled—normally within 15 minutes. It is advisable to delay any remaining dental procedures to allow adequate healing of the affected tissues. The horse should be observed periodically for at least 1 to 2 days for evidence of further hemorrhage.

Soft Tissue Trauma and Infection

A wolf tooth that fractured during extraction from a 2-year-old Quarter horse stallion. A 25-gauge, –58 -inch needle has been inserted into the apical end of the pulp chamber.

260

Soft tissue infections, sepsis, and tetanus have reportedly occurred after wolf tooth extraction.3,11,12 Therefore, it is wise to assess the patient’s vaccination history and administer tetanus prophylaxis, if indicated.12 During wolf tooth extraction, the gingiva, palatine mucosa, and oral mucosa may be accidentally torn or lacerated, and these tissues may become infected with organisms from the oral cavity.

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FREE CE Extraction of the First Premolar Teeth

FIGURE 7

CriticalPo nt Complications of the extraction procedure include excessive hemorrhage due to iatrogenic trauma to the major palatine vessels.

The maxilla and hard palate region of a juvenile horse skull. Near the lateral border of the hard palate on each side, the greater palatine artery runs forward from the palatine foramen (yellow arrows) near the cheek teeth within the palatine groove (red arrows). Continuing rostrally along the bone, the vessels curve axially near the corner incisors (Triadan 103 and Triadan 203) and enter the incisive foramen (blue arrow). A single wolf tooth is present in this specimen (green arrow; Triadan 205).

If accidental laceration or tearing of mucosa occurs, the owner should be instructed to irrigate the injured tissue with water, saline, or dilute chlorhexidine solution to cleanse the defect until healing is complete.

Incomplete Removal of the Tooth If an equine patient exhibits bitting problems after removal of wolf teeth, the extraction sites should be visualized and palpated to detect the presence of pain, draining tracts, or sharp tooth remnants. If a fractured wolf tooth remnant projects past the rim of the alveolus, the patient may experience pain when ridden with a bit.8,11 In these cases, the fractured root remnant should be elevated and removed. Sharp bony enlargements associated with the extraction site should be smoothed with a curette or rongeur in any equine patient experiencing bitting problems after wolf tooth removal.

Aftercare The vast majority of equine patients do not

262

experience complications after wolf tooth extraction, and aftercare tends to be minimal in most practices (FIGURE 8). One report advocates that horses should not be fed hay or bedded on straw for 12 hours after extraction. This report also recommends that any grain concentrate should be fed as a mash for the ﬁrst 12 hours after surgery.5 If lower wolf teeth have been extracted, the extraction sites may become packed with feed material or infected, possibly delaying healing. Therefore, it is important to instruct the owner to irrigate these sites twice daily after surgery until the wounds have epithelialized. To minimize the development of alveolar osteitis, lower wolf teeth extraction sites may be packed with gel foam or gauze after surgery.1,6 I generally recommend that affected patients not be ridden or bitted for 24 hours after wolf tooth extraction, after which normal training may commence. Some veterinarians advocate that the patient’s mouth should not be bitted for a longer period after wolf tooth extraction in

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Extraction of the First Premolar Teeth CE FIGURE 8

A 2-year-old Quarter horse stallion with a small amount of bleeding from the gingival and alveolar tissues, which can be expected during and immediately after wolf tooth removal.

order to allow epithelialization of the extraction sites.5,7 Postoperative administration of analgesics (e.g., phenylbutazone [2.2 mg/kg PO q12h for several days]) may be indicated in some cases, such as those that require lengthy, difﬁcult extraction procedures.

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Conclusion Veterinarians are frequently asked by owners and trainers to examine riding horses of all ages for suspected dental problems and for behavioral problems that may be associated with oral pain. The patient may demonstrate oral discomfort in several ways, including head tossing and head shaking. (A basic knowledge of the types of bits and bridles used for riding horses and how these instruments function can be very helpful in evaluating and treating affected patients.) Wolf teeth may cause discomfort due to bit pressure forcing the cheek mucosa against the sharp point of the tooth or due to bit contact against the mucosa overlying an unerupted wolf tooth. Therefore, veterinarians often remove wolf teeth from horses. The extraction procedures described in this article are straightforward and yield successful outcomes if the veterinarian is adequately prepared with the proper instrumentation and proceeds with patience on an adequately sedated and restrained horse that has been administered a local anesthetic before initiation of the extraction procedure.

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Acknowledgments The author acknowledges the following individuals at Texas A&M University’s College of Veterinary Medicine for their assistance in preparing this article: Larry Wadsworth, medical photographer, College of Veterinary Medicine Media Resources; Kathrin R. Burke, DrMedVet, Department of Veterinary Pathobiology; Kyle Westfall, veterinary technician, Veterinary Medical Teaching Hospital; and Betsy McCauley, veterinary radiologic technologist, Veterinary Medical Teaching Hospital.

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FREE CE Extraction of the First Premolar Teeth

References 1. Easley KJ. Equine canine and ﬁrst premolar (wolf) teeth. Proc AAEP 2004:(50):13-18. 2. Linkous MB. Performance dentistry and equilibration. Clin Tech Equine Pract 2005;4(2):124-134. 3. Gaughan EM. Dental surgery in horses. Vet Clin North Am Equine Pract 1998;14(2): 381-397. 4. Scrutchﬁeld L, Schumacher J. Examination of the oral cavity and routine dental care. Vet Clin North Am Equine Pract 1993;9(1):123-131. 5. Stelzer P. Die Extraktion des Wolfszahnes beim. [Preferred extraction of the wolf tooth in horses.] Prakt Tierarzt 85:Heft 2004;(3):188-189. 6. Baker G, Easley J. Corrective dental procedures. In: Equine Dentistry. 2nd ed. Philadelphia: Elsevier; 2005:221-248.

7. Lowder M. Dental conditions affecting the young horse, birth to 2 years. Focus on Dentistry Proc AAEP 2006:203-205. 8. Scrutchﬁeld WL. Wolf teeth: how to safely and effectively extract and is it necessary. Focus on Dentistry Proc AAEP 2006:56-60. 9. Sisson S, Grossman JD. Anatomy of Domestic Animals. 4th ed. Philadelphia: WB Saunders; 1953. 10. Nickel R, Schummer A, Seiferle E. The Viscera of Domestic Mammals. 2nd ed. Philadelphia: Springer-Verlag; 1979:95. 11. Dixon PM, Dacre I. A review of equine dental disorders. Veterinary J 2005;169:165-187. 12. Baker G, Easley J. Dental and oral examination. In: Equine Dentistry. Philadelphia: WB Saunders; 1999:151-169.

3 CE CREDITS

CE TEST 1 This article qualiﬁes for 3 contact hours of continuing education credit from the Auburn University College of Veterinary Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumEquine.com. Those who wish to apply this credit to fulﬁll state relicensure requirements should consult their respective state authorities regarding the applicability of this program.

1. Erupted wolf teeth a. are more common on the upper arcade. b. may be present on the lower arcade. c. may cause discomfort in some horses due to movement of the bit during riding. d. all of the above 2. Which statement(s) regarding wolf teeth in horses is/are correct? a. A wolf tooth may erupt during the ﬁrst year of life. b. A wolf tooth may be present in each of the four dental arcades. c. Wolf teeth are considered to be functionless. d. all of the above 3. Blind wolf teeth are also known as a. canine teeth. b. impacted wolf teeth. c. unerupted wolf teeth. d. b and c 4. Which of the following may be used before wolf tooth extraction in order to improve the patient’s comfort? a. placement of the patient in a stanchion b. administration of local anesthetic to desensitize the extraction site

b. soft tissue infection c. mandibular alveolar osteitis d. all of the above

c. administration of a sedative or analgesic (e.g., xylazine) d. b and c 5. Which statement(s) regarding the removal of erupted upper wolf teeth is/ are correct? a. An elevator may be used to carefully pry and loosen the tissue around a wolf tooth. b. A Burgess instrument may be used to cut the gingiva around a wolf tooth. c. Proper use of a mallet can help loosen wolf teeth that are difﬁcult to remove. d. all of the above 6. If the wolf tooth fractures during extraction, a. loose fragments of bone or tooth should not be disturbed. b. fractured root remnants protruding past the rim of the alveolus should not be disturbed. c. it is unnecessary to inspect the extraction site and alveolus if the tooth was fractured. d. none of the above 7. Which of the following may result from tooth extraction in horses? a. excessive hemorrhage due to laceration of the major palatine vessels

8. If a patient exhibits abnormal bitting behavior after wolf tooth removal, a. the extraction site should be visualized and digitally palpated. b. removal of the permanent second premolar is indicated. c. a thorough oral examination is not necessary. d. none of the above 9. If lower wolf teeth are removed, a. the extraction sites should be rinsed of debris twice daily until the wound is healed. b. the canine teeth should also be extracted. c. postoperative infection and poor healing of the extraction sites could occur. d. a and c 10. If a fractured wolf tooth remnant projects past the rim of the alveolus, a. the remnant should not be disturbed. b. the remnant should be removed. c. the gingiva should be sutured over the remnant for padding. d. a and c

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Fare Thee Well

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How to help owners (and yourself) deal with the death of a horse

❯❯ Amy I. Bentz, VMD, DACVIM Veterinary Learning Systems Yardley, Pennsylvania

❯❯ Christina Bach, MSW, LSW Director of Clinical Social Work and Pet Bereavement Services University of Pennsylvania

I hold it true, whate’er befall; I feel it, when I sorrow most; ‘Tis better to have loved and lost Than never to have loved at all.

At a Glance Practice Being “The Gentle Doctor” Page 268

Remember the Five Stages of Grief Page 268

Recall the Veterinarian’s Oath Page 269

Express Your Sympathy Page 270

Seek Assistance Page 270

Avoid Burnout Page 273

—In Memoriam A. H. H. (from Canto 27; 1849) by Alfred, Lord Tennyson Imagine the following: During an already hectic day, one of your best clients calls you and simply says, “Doc, it’s time.” You agree, reschedule your other appointment, and drive to the farm quickly, knowing the scene that awaits. Your client’s 35-year-old Thoroughbred gelding, Skip, has been losing weight and falling down recently. Until now, the owner has been able to help Skip stand. But now Skip is recumbent and listless, so the owner has decided to have him euthanized. or During an already hectic day, one of your best clients calls you, crying, and says, “My daughter’s horse, Breeze, jumped out of the paddock, ran into the road, and was hit by

a car. Please come quickly.” You jump into your truck, knowing the grim scene that awaits as the mother and daughter try to comfort their dying horse. Are you prepared to handle these situations? Would you know what to say to the owners? In the case of Skip, could better planning have helped avoid disruption in your chronically packed schedule? This article on grief and euthanasia addresses some common questions equine veterinarians have when counseling owners before and after having their horses euthanized. In veterinary school, we are trained in the science of veterinary medicine. We learn how to diagnose, treat, and prevent various maladies, but we cannot learn the art of veterinary medicine until we begin to practice. After graduation, we quickly realize how vital it is to effectively communicate with clients to achieve the goal of treating equine patients properly. It can be daunting to simultaneously handle

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Fare Thee Well the equine patient’s medical problem and the owner’s emotional concerns.1 When we deal with a tense situation such as euthanasia, the need to communicate effectively becomes even more critical. While personal communication styles differ, the information in this article can help even the most seasoned veterinarian handle euthanasia and grief more easily.

CriticalPo nt In veterinary school, we are trained in the science of veterinary medicine. We learn how to diagnose, treat, and prevent various maladies, but we cannot learn the art of veterinary medicine until we begin to practice.

Practice Being “The Gentle Doctor”

Our profession is held in high regard in our society, and by practicing compassionate care, we reafﬁrm our unique posiRemember the tion as trusted professionals. Five Stages of Grief “The Gentle Doctor” sculpture “The Gentle Doctor” by Christian Peterson. In On Death and Dying, by Christian Peterson at the (Reprinted with permission from Iowa State Dr. Elizabeth Kübler-Ross Iowa State University College University College of Veterinary Medicine) described the ﬁve stages of of Veterinary Medicine depicts a caring veterinarian cradling a sick puppy while grief (TABLE 1). Although not everyone experithe mother dog looks up with concern (FIGURE 1). ences this process in the same way and may Although this is not a sculpture of an equine not exhibit each stage, these stages are comveterinarian, it epitomizes the compassion we mon reactions to loss. The owner’s emotions

The Five Stages of Grief

TABLE 1

Stage a

1. Denial

The Owner’s Reaction

Recommended Response by the Veterinarian

The owner cannot comprehend the horse’s illness or impending death.1

Give the owner time to ask questions and think about your conversation so he or she can adjust to this new reality.3

The owner may seem dazed or confused and unable to make decisions.1 2. Angera

The owner may lash out at you or your staff and may refuse to pay the bill.1 Guilt may accompany this stage.1

Give the owner time to ask questions and process the new information so he or she can adjust to this new reality.3

3. Bargaininga

The owner may ask for a second opinion or wish to pursue unusual treatments to attempt to gain control over the situation.3

Listen to the owner, acknowledge his or her feelings, be sympathetic, and explain treatment options so the owner can participate in the decision.3

4. Depressiona

This is the true stage of bereavement, when the owner mourns the loss of the horse. This stage is marked by periods of crying and extreme grief.3

Listen to the owner, be sympathetic, and treat the horse with compassion.3

5. Acceptancea

The owner ﬁnally accepts the loss and may remember the horse with sadness but does not cry uncontrollably.1,3

—

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should all have toward our patients, large or small, and their owners. An especially critical time for the veterinarian–client bond is when we recommend euthanasia for a critically ill horse. We cannot eliminate our clients’ pain, but we can decrease their grief and anxiety with patience and compassion.1 By spending a few minutes to explain and listen, we offer owners a chance to process information before making a permanent decision to euthanize their horse. After euthanasia, this can help owners feel better about their decision.

FIGURE 1

Kübler-Ross E. On Death and Dying. New York: Scribner; 1969.

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Fare Thee Well depend on whether the loss is sudden and tragic (as in the case of Breeze) or involves gradual deterioration of the horse (as in the case of Skip). Many owners are deeply attached to their horses and may have owned them for 20 years or more. Owners may view their horses as companions whose loss will leave a large void in the owner’s life. The situation is even more complex if the horse is loved by a child and the parents look to you for comfort and advice. When speaking with your clients, remember that they may be experiencing a variety of emotions. If they are considering having their horse euthanized, they may need some time to adjust to the idea. If the horse is not critically ill, it may help them to think about the decision to euthanize and to call family and friends before giving permission. When dealing with geriatric horses, such as Skip, it is often important to discuss the horse’s deterioration with the owners. Older horses in poor body condition that are not responding to treatment, feeding, or management changes often have trouble during the winter, such as slipping and falling on snow or ice. The owner may not recognize the horse’s gradual deterioration or the potential consequences. If the owner is given time to think about euthanasia and decides to have it performed, other family members might want to be present. The owners may choose to euthanize their horse on a sunny, warm day so the family can say goodbye in an optimal environment, allowing you to schedule your time appropriately to prepare for the procedure and avoid interruptions. Each situation offers an opportunity to serve our patients and their owners.

Recall the Veterinarian’s Oath “Being admitted to the profession of veterinary medicine, I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health, the relief of animal suffering…”2 Although grief and euthanasia are difficult, we can end the horse’s suffering and bring some comfort to owners and caretakers, especially in catastrophic situations. When I (A. I. B.) was in ambulatory practice, one of my worst cases requiring euthanasia involved a beautiful, young Thoroughbred mare. She had been turned out overnight and inexplicably broke her leg in a level, open paddock. When

I arrived on the farm and quickly examined her, she had shattered her left third metacarpal bone, and only soft tissue held the limb together. Although the scenario was very tragic, I was grateful to be able to end the mare’s suffering and offer comfort to the owners. BOX 1

Additional Resources American Veterinary Medical Association Equine euthanasia www.avma.org/careforanimals/ animatedjourneys/goodbyefriend/ equineuth.asp The Argus Institute for Families and Veterinary Medicine College of Veterinary Medicine & Biomedical Sciences Colorado State University www.argusinstitute.colostate.edu (Grief information for veterinarians and pet owners) Horsehair Jewelry www.ponylocks.com www.twistedtails.com A New Paradigm for Equine Euthanasia Carolyn Butler, MS www.aaep.org/health_articles_view. php?print_friendly=true&id=175

CriticalPo nt Our profession is held in high regard in our society, and by practicing compassionate care, we reafﬁrm our unique position as trusted professionals.

The Veterinary Social Work Program at the Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania www.vet.upenn.edu/RyanHospital/ VeterinarySocialWork/tabid/255/Default.aspx BOX 2

AAEP Guidelines for Recommending Euthanasiaa The following criteria should be considered in evaluating the immediate necessity for euthanasia of a horse to avoid and terminate incurable and excessive suffering: 1. Is the medical condition chronic and incurable? 2. Does the immediate medical condition have a hopeless prognosis for life? 3. Is the horse a hazard to itself or its handlers? 4. Will the horse require continuous medication for the relief of pain for the remainder of its life? 5. Will the medical condition result in a lifetime of continued individual conﬁnement? a

2007.

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Fare Thee Well Express Your Sympathy

CriticalPo nt An especially critical time for the veterinarian–client bond is when we recommend euthanasia for a critically ill horse. We cannot eliminate our clients’ pain, but we can decrease their grief and anxiety with patience and compassion.

There are no perfect words to say to owners experiencing loss. Often, the best approach is to express your sympathy and listen to the owner. Sending a card and/or ﬂowers is an excellent way to express your condolences.3,a If you knew the horse well, write down a memory or two, and the card will be treasured by the owner. Some practices collect mane or tail hair for making into bracelets and other jewelry through various outletsa (BOX 1). Some practices call clients to check on them a few days after their horse died or was euthanized. This can be very helpful for owners who may need reassurance that they made the correct decision. Some practices memorialize the patient through a donation to an animal shelter or a research fund and send a card to notify the owner.

Seek Assistance The human–animal bond is increasingly recognized in our society as a powerful and unique relationship.1,4 This bond offers much-needed comfort and companionship in our hectic

Drs. Tamera McNamara, Jennifer Proctor, Cathleen Lombardi, Jean Feldman, and Valerie Devaney. Personal communication, Veterinary Information Network, January 30, 2009, through February 1, 2009.

TABLE 2

Five Common Client Reactions to Pet Lossa

Client Reaction

Example

Recommended Response by the Veterinarian

1. Guilt

The owner may ask, “Did I wait too long to euthanize, or did I euthanize too quickly?” The owner may feel guilty months after the pet’s death and may contact you for reassurance.

Listen to the owner and reassure him or her that the correct decision was made.

2. Shame

The owner may feel ashamed to tell anyone or may be afraid someone will say, “It was only an animal, you can always get another one.”

Reassure the owner that the horse is unique or special and will not be replaced by a new addition.

3. Relief

If the animal dies before the owner makes a decision to euthanize, the owner may feel relief that he or she did not have to make the ﬁnal decision to end the pet’s life.

—

4. Loneliness

—

Be sympathetic and supportive. Provide a list of pet loss support hotlines and other resources.

5. Yearning

—

Be sympathetic and supportive. Provide a list of pet loss support hotlines and other resources.

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lives, even improving our mood and blood pressure values! However, when our beloved animals are experiencing terminal suffering, the topic of euthanasia should be addressed (BOX 2). Many veterinary schools offer a pet loss support hotline (BOX 3) and support groups for small animal owners experiencing the loss of a pet. For example, the University of Pennsylvania School of Veterinary Medicine offers a program for pet owners, including grief counseling and bereavement. I (C. B.) teach veterinary students to be aware of ﬁve common reactions clients may exhibit after their pet has died or been euthanized (TABLE 2). I also tell my students, “People need to want help; they will seek you out if they require more assistance.” If an owner is demonstrating a persistent need to discuss his or her horse’s disease and death, it may help to refer the owner to a health professional. Children are often involved in equine activities and develop strong attachments to horses, so it can be very traumatic for a child to lose a horse. Honesty is the best policy when explaining the horse’s death to a child, but use developmentally appropriate language. The child wants to understand what happened, so use simple terms; however, do not say, “The horse was put to sleep,” because the child may become afraid to sleep. The child needs time

Developed by Christina Bach, MSW, LSW, Director of Clinical Social Work and Pet Bereavement Services, University of Pennsylvania.

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Fare Thee Well BOX 3

Pet Loss Support Hotlinesa `352-392-4700, then dial 1 and 4080; staffed by Florida community volunteers; weekdays, 7:00 PM to 9:00 PM Eastern time; or 352-392-4700, ext 4744, at the University of Florida

`517-432-2696; staffed by Michigan State University veterinary students; Tuesday through Thursday, 6:30 PM to 9:30 PM Eastern time; cvm.msu.edu/ petloss/index.htm

`630-325-1600; staffed by Chicago Veterinary Medical Association veterinarians and staffs; leave voice mail message; calls will be returned 7:00 PM to 9:00 PM Central time; long-distance calls will be returned by collect call

`540-231-8038; staffed by VirginiaMaryland Regional College of Veterinary Medicine; Tuesday, Thursday, 6:00 PM to 9:00 PM Eastern time

`614-292-1823; staffed by The Ohio State University veterinary students; Monday, Wednesday, Friday, 6:30 PM to 9:30 PM Eastern time; voice mail messages will be returned by collect call during operating hours

CriticalPo nt Honesty is the best policy when explaining the horse’s death to a child, but use developmentally appropriate language.

`508-839-7966; staffed by Tufts University veterinary students; Monday through Friday, 6:00 PM to 9:00 PM Eastern time; voice mail messages will be returned daily (by collect call outside of Massachusetts); www.tufts.edu/vet/petloss

`888-ISU-PLSH (888-478-7574); hosted by the Iowa State University College of Veterinary Medicine; operational 7 days/week, 6:00 PM to 9:00 PM Central time from September through April and Monday, Wednesday, Friday, 6:00 PM to 9:00 PM Central time from May through August

`607-253-3932; staffed by Cornell University veterinary students; Tuesday through Thursday, 6:00 PM to 9:00 PM Eastern time; messages will be returned; www.vet.cornell.edu/Org/PetLoss

`217-244-2273 or 877-394-2273 (CARE); staffed by University of Illinois veterinary students; Sunday, Tuesday, Thursday, 7:00 PM to 9:00 PM Central time; www.cvm.uiuc.edu/CARE

`970-491-4143; Argus Institute grief resources, Colorado State University `509-335-5704; Washington State University College of Veterinary Medicine; staffed during the semester on Monday, Tuesday, Wednesday, Thursday, 6:30 PM to 9:00 PM, and Saturday, 1:00 PM to 3:00 PM Paciﬁc time; www.vetmed.wsu.edu/PLHL a

Accessed February 2009 at www.avma.org/careforanimals/animatedjourneys/goodbyefriend/plhotlines.asp.

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Presented by: American College of Veterinary Surgeons American Association of Equine Practitioners American College of Veterinary Anesthesiologists American Veterinary Dental College Veterinary Emergency and Critical Care Society

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Fare Thee Well to grieve and may want to memorialize the horse by making a scrapbook, having a memorial service, or burying the horse’s ashes. It is important for parents to inform school ofﬁcials that their child has lost a pet. If behavioral changes or depression are noted, the child may need to talk with a professional counselor.

CriticalPo nt It is important for parents to inform school ofﬁcials that their child has lost a pet. If behavioral changes or depression are noted, the child may need to talk with a professional counselor.

Avoid Burnout It is vital for you to maintain your mental health. You may have treated a horse for years, becoming a member of its family, so you also may experience grief at the loss of the horse.5 It is important to recognize these feelings and express them in your own way. Owners will be very touched to see your grief and compassion at the loss of their horse, forging a stronger bond between them and you. However, it is equally important to take time to refresh yourself and maintain perspective. See BOX 1 for additional resources to help yourself and your clients.

Conclusion Our equine patients are often treasured members of the family and are mourned when they die or are euthanized. We hope the information in this article will help you practice the art of veterinary medicine when handling grief and euthanasia.

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Bertone J. Grief support techniques in a bondcentered equine practice. In: Equine Geriatric Medicine and Surgery. New York: Elsevier Health Sciences; 2006. Kübler-Ross E, Kessler D. On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. New York: Scribner; 2005. Lagoni L, Butler C, Hetts S. The Human-Animal Bond and Grief. New York: Harcourt Brace; 1994.

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References 1. Lawrence EA. Euthanasia and the human–equine bond. Equine Pract 1993;15(10):34-44. 2. Veterinarian’s oath. Adopted by the House of Delegates, July 1969; amended by the Executive Board, November 1999. Accessed February 2009 at www.avma.org/about_avma/whoweare/oath.asp. 3. Brackenridge SS, Shoemaker RS. The human/horse bond and client bereavement in equine practice, part 2. Equine Pract 1996; 18(2):23-25. 4. Brackenridge SS, Shoemaker RS. The human/horse bond and client bereavement in equine practice, part 1. Equine Pract 1996; 18(1):19-22. 5. Brackenridge SS, Shoemaker RS. The human/horse bond and client bereavement in equine practice, part 3. Equine Pract 1996; 18(4):20-23.

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Therapeutics in Practice Current medical protocols for treating a variety of conditions in horses

Treating Methicillin-Resistant Staphylococcus aureus Infection ❯❯ J. Scott Weese, DVM, DVSc, DACVIM* University of Guelph Guelph, Ontario, Canada

At a Glance Clinical Presentation Page 274

Diagnosis Page 274

Principles of Treatment Page 275

Colonization Page 275

Infection Control Page 276

Prognosis Page 276

Series Editor ❯❯ Debra Deem Morris, DVM, MS, DACVIM 190 State Route 10 East Hanover, NJ 07936 phone 973-599-1191 fax 973-599-1193 e-mail stretchdeem@yahoo.com

ethicillin-resistant Staphylococcus aureus (MRSA) is a critically important human pathogen and an emerging problem in equine medicine. It is associated with various opportunistic infections in horses, in both veterinary hospitals and the general population, and can be transmitted readily between horses and humans. MRSA isolates are resistant to β-lactam antimicrobials (penicillins, cephalosporins, carbapenems) because they have a gene (mecA) that encodes for production of a penicillin-binding protein with low afﬁnity for all β-lactams. In addition, MRSA isolates are often resistant to other antimicrobials. In some situations, there may be few treatment options. The incidence of MRSA infection in horses is unclear; however, anecdotally, it seems to be on the rise. MRSA is endemic in the equine population and can be carried by a small percentage (up to 5%) of healthy horses through colonization, mainly in the nasal passages.1–3 The ability of MRSA to reside in healthy horses can allow the organism to silently increase in a population, with opportunistic infections occurring sporadically or in outbreaks. People who work with horses, particularly veterinarians, have abnormally high rates of MRSA colonization (10% to 15%),4,5 and zoonotic infections have been reported.6,7

Clinical Presentation *Dr. Weese discloses that he has received ﬁnancial beneﬁts from Nutramax and Antech Diagnostics as well as research support from Royal Canin.

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Like methicillin-susceptible S. aureus, MRSA is an opportunistic pathogen that can cause a wide range of clinical presentations— from mild skin infection to rapidly fatal

septicemia.1,6 Wound and surgical infections are most common,6,8,9 but MRSA needs to be considered as a possible cause of any opportunistic infection.

Diagnosis The diagnosis of MRSA infection is relatively straightforward if culture specimens are collected and the diagnostic laboratory uses adequate procedures to identify MRSA. Identiﬁcation of MRSA is critical for early implementation of appropriate treatment and infection control measures. The need for collecting appropriate culture specimens cannot be overemphasized. Swabs or samples should be collected from infected sites as early as possible in the disease process. To reduce the risk of contamination by commensal microﬂora, aseptic technique should be used when collecting samples from normally sterile sites.

TO LEARN MORE 2008 ACVIM Forum Conference Highlights (July/August 2008) The Editor’s Desk: The Emergence of Some Mighty Microbes (May/ June 2007) Pathogenesis of Staphylococcus aureus Pneumonia (Winter 2006) Related content on

CompendiumEquine.com

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Treating Methicillin-Resistant Staphylococcus aureus Infection Principles of Treatment There has been no objective evaluation of different treatment approaches for MRSA infection in horses. Treatment decisions should be based on a variety of factors, including infection severity and location as well as antimicrobial susceptibility of the MRSA strain. Although MRSA receives much attention, it is important to remember that MRSA is still S. aureus, but just more resistant to antimicrobials.

Antimicrobial Therapy In general, in vitro antimicrobial susceptibility results are reliable; however, a few points must be considered (BOX 1). Fluoroquinolone susceptibility is commonly reported in vitro for equine MRSA6,8,9; however, response to fluoroquinolones is unpredictable in humans, despite in vitro susceptibility, and resistance can develop quickly, even during treatment. Therefore, fluoroquinolones are not considered appropriate for treating MRSA in humans, and there is no reason to think that the situation would be different in horses. Otherwise, antimicrobial choices should be made based on the antimicrobial susceptibility in conjunction with relevant factors, such as infection site (ability of the drug to penetrate), infection character (presence of organic debris), patient age, and patient health status (e.g., renal compromise). Currently, there is typically at least one reasonable antimicrobial option for treating MRSA infection in horses. Chloramphenicol is commonly used because of its efficacy, cost, oral route of administration, and safety. The main concern regarding chloramphenicol is human health risks from exposure to the drug; therefore, it is important to ensure that farm personnel can safely handle the drug. Trimethoprim–sulfonamide susceptibility is uncommon in equine isolates,1,6,8 but when it is

β-Lactam Antimicrobials

BOX 1

There can be variable expression of the mecA gene in vitro, and it is possible that an isolate could appear susceptible to one or more β-lactam antimicrobials in vitro. However, clinical response is unlikely, and all MRSA isolates must be considered resistant to all β-lactam antimicrobials.

present, this drug combination is an excellent treatment option because it can be administered orally and is relatively safe for use in equine patients. Aminoglycosides may be effective in some situations, but resistance is common.1,6,8,9 Consideration of the infection site is important to ensure that the drug has a reasonable chance of reaching therapeutic levels at the site and is less likely to be inactivated by organic debris. In humans, drugs such as vancomycin and linezolid are commonly used. In addition to being expensive, use of these drugs in horses is controversial because of the importance of these drugs in human medicine and concerns about further emergence of antimicrobial resistance. It is questionable whether these drugs should be used in veterinary medicine; if they are used, it must be only when absolutely necessary. Many MRSA infections may be amenable to local therapy, either as a sole or an adjunctive treatment. Topical application of antimicrobials such as mupirocin or fusidic acid could be effective in treating superﬁcial infections, although there are concerns about emergence of resistance to these drugs. Topical application of antiseptic solutions such as 0.2% chlorhexidine digluconate or 1% acetic acid may also be useful. Other antibacterial compounds, such as tea tree oil, have anti-MRSA properties, but their in vivo efﬁcacy is unknown.

CriticalPo nt MRSA is an emerging equine and zoonotic pathogen. MRSA infection is not always lifethreatening. Most affected horses respond to appropriate treatment.

Adjunctive Therapy Adjunctive therapeutic measures, such as surgery, joint lavage, or ﬂuid therapy, may play an important role in successful treatment of MRSA infection. The success of these therapies depends on the location and severity of the infection, not the presence of MRSA.

Colonization It is logical to want to eliminate MRSA colonization because colonized horses are at increased risk of developing a clinical infection in certain situations3 and may be a source of infection for other horses or humans. However, the need for this approach and methods of decolonization therapy are unclear. Transient MRSA colonization seems to be the norm in horses, and most, if not all, horses eliminate MRSA colonization naturally if reinfection is prevented.10 Furthermore, there is no evidence that antimicrobial therapy is effective at eliminating MRSA colonization in horses. Systemic

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Therapeutics in Practice Important Aspects of MRSA Control BOX 2

The use of contact precautions (gloves, protective outerwear) when handling infected animals Isolation of infected animals Careful attention to personal hygiene (especially hand hygiene) Proper application of routine cleaning and disinfection practices

and nebulized antimicrobials were ineffective in one uncontrolled study,10 and it is difﬁcult to envision how to adequately treat the nasal passages of a horse with a topical antimicrobial, which is the standard approach in humans. Because colonization appears to be transient and antimicrobial use could further contribute to the development of resistance, the use of antimicrobials for active decolonization is not currently recommended. Colonized horses should be handled using appropri-

CriticalPo nt While MRSA infection appears similar to infections caused by susceptible bacteria, treatment of MRSA infection is complicated by limited antimicrobial options. Prompt diagnosis by culture and susceptibility testing and early implementation of appropriate treatment are critical.

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Ontario Veterinary College MRSA Control Program BOX 3

All horses are screened for MRSA by nasal swab at admission, weekly during hospitalization, and at the time of discharge. Infected or colonized horses are isolated and handled with contact barrier precautions (i.e., gloves, gown, overboots). Gloves are worn when contact with mucous membranes, wounds, and possibly infected sites is expected and when invasive devices (i.e., intravenous catheters) are used. The diagnostic laboratory immediately contacts Infection Control when MRSA is isolated. The Infection Control practitioner then notiﬁes all relevant personnel. MRSA isolates are saved and typed to provide more information about the epidemiology of MRSA in the hospital and community. Farms with a history of horses with MRSA are asked if they are interested in trying to eradicate MRSA through testing and infection control practices. People are not regularly screened for MRSA. The only indication to institute voluntary and conﬁdential screening is when epidemiologic evidence of personnel-borne transmission exists and when improvements in infection control practices have not had an effect.

ate infection control precautions and retested periodically to determine whether they are still colonized.

Infection Control Careful application of infection control practices is important in reducing the risk of MRSA transmission from infected horses to other horses or to people who work with them (BOXES 2 AND 3). Additional measures, including active screening of horses to identify carriers, may be useful in some circumstances. Prudent antimicrobial use is also important.

Prognosis It is important to understand that the prognosis for MRSA infection in horses depends more on the severity and location of the infection than on the fact that MRSA is involved, as long as MRSA is identiﬁed early and appropriate antimicrobial therapy is initiated. A recent multicenter study reported that 84% of horses with MRSA infection were discharged.11 This study did not compare this outcome with the outcome for infections caused by other bacteria but highlights the fact that treatment of MRSA infection is certainly not hopeless. With appropriate treatment, it is likely that the prognosis for MRSA infection is no different than that for infections caused by susceptible strains.

Conclusion MRSA is an emerging problem that will, unfortunately, become more common in coming years.

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Treating Methicillin-Resistant Staphylococcus aureus Infection

A combination of good infection control and prudent antimicrobial use may limit the effect of this pathogen in horses and their human contacts, but the ability of MRSA to reside in the nasal passages of healthy horses makes eradi-

cation of MRSA from the equine population unlikely. However, despite the potential severity of MRSA infection, most infections are treatable with prompt diagnosis and implementation of a logical treatment regimen.

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References 1. Baptiste K, Williams K, Willams N, et al. Methicillin-resistant staphylococci in companion animals. Emerg Infect Dis 2005;11: 1942-1944. 2. Weese J, Rousseau J, Traub-Dargatz J, et al. Community-associated methicillin-resistant Staphylococcus aureus in horses and humans who work with horses. JAVMA 2005;226:580-583. 3. Weese JS, Rousseau J, Willey BM, et al. Methicillin-resistant Staphylococcus aureus in horses at a veterinary teaching hospital: frequency, characterization, and association with clinical disease. J Vet Intern Med 2006;20:182-186. 4. Anderson ME, Lefebvre SL, Weese JS. Evaluation of prevalence and risk factors for methicillin-resistant Staphylococcus aureus colonization in veterinary personnel attending an international equine veterinary conference. Vet Microbiol 2008;129:410-417. 5. Hanselman B, Kruth S, Rousseau J, et al. Methicillin-resistant Staphylococcus aureus colonization in veterinary personnel. Emerg Infect Dis 2006;12:1933-1938. 6. Weese J, Archambault M, Willey B, et al. Methicillin-resistant

Staphylococcus aureus in horses and horse personnel (20002002). Emerg Infect Dis 2005;11:430-435. 7. Weese JS, Caldwell F, Willey BM, et al. An outbreak of methicillin-resistant Staphylococcus aureus skin infections resulting from horse to human transmission in a veterinary hospital. Vet Microbiol 2006;114:160-164. 8. Oâ&#x20AC;&#x2122;Mahony R, Abbott Y, Leonard F, et al. Methicillin-resistant Staphylococcus aureus (MRSA) isolated from animals and veterinary personnel in Ireland. Vet Microbiol 2005;109:285-296. 9. Seguin JC, Walker RD, Caron JP, et al. Methicillin-resistant Staphylococcus aureus outbreak in a veterinary teaching hospital: potential human-to-animal transmission. J Clin Microbiol 1999;37:1459-1463. 10. Weese J, Rousseau J. Attempted eradication of methicillin-resistant Staphylococcus aureus colonisation in horses on two farms. Equine Vet J 2005;37:510-514. 11. Anderson MEC, Lefebvre SL, Rankin SC, et al. A prospective study of methicillin-resistant Staphylococcus aureus infections in 115 horses. Equine Vet J 2008; in press.

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Vestibular Disease: Temporohyoid Osteoarthropathy* ❯❯ Bonnie R. Rush, DVM, MS, DACVIMa ❯❯ Jason A. Grady, DVM Kansas State University

T At a Glance Diagnostic Criteria Page 279

Treatment Recommendations Page 280

Prognosis Page 282

emporohyoid osteoarthropathy is a common cause of peripheral vestibular disease in horses. This disorder should be the primary diagnostic differential in cases of acute-onset vestibular dysfunction with facial nerve paralysis. The cause of temporohyoid osteoarthropathy is unknown; however, septic and nonseptic degenerative processes have been proposed. Neurologic dysfunction in horses with temporohyoid osteoarthropathy is an acute manifestation of chronic bony proliferation of the petrous temporal bone and stylohyoid bone, resulting in ankylosis of

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*Updated by the authors and reprinted with permission from Standards of Care: Equine Diagnosis and Treatment 2001;1.1:5-7. a Dr. Rush discloses that she has received ﬁnancial beneﬁts from Fort Dodge Animal Health.

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the temporohyoid joint. The hyoid apparatus is linked to the tongue and larynx; therefore, fusion of the temporohyoid joint impairs ﬂexibility of the unit. In this disease process, mastication or vocalization transfers lingual and pharyngeal forces to the stylohyoid bone, producing osseous proliferation and eventual fracture of the stylohyoid bone or petrous temporal bone. Neurologic signs are not initially apparent during formation of proliferative osteitis and temporohyoid joint fusion. However, in the later stages of disease, the petrous temporal bone fractures, causing neurologic signs associated with temporohyoid osteoarthropathy. The fracture line extends into the cranial vault at the level of the internal auditory meatus, inducing direct trauma to the vestibulocochlear and facial nerves and hemorrhage into the middle and inner ear. Occasionally, the fracture line extends to the foramen lacerum, caudal to the petrous temporal bone, where the glossopharyngeal and vagal nerves exit the skull. Trauma to these nerves caused by the fracture may result in dysphagia for several days. Inﬂammation from the disease process may extend through the internal acoustic meatus and lead to focal suppurative meningitis

Compendium Equine: Continuing Education for Veterinarians® | July/August 2009 | CompendiumEquine.com

Vestibular Disease: Temporohyoid Osteoarthropathy at the level of the pons, resulting in fever and depression. Secondary meningitis worsens the prognosis for recovery. Rupture of the tympanic membrane and drainage of exudate from the external meatus occur in horses but are probably unrecognized in most cases.

Diagnostic Criteria Historical Information

Endoscopic examination of the guttural pouch identiﬁes osseous proliferation of the proximal insertion of the stylohyoid bone at the level of the temporohyoid joint (FIGURE 1). This condition can be unilateral or bilateral, so it is important to endoscopically examine both guttural pouches.

Radiography

Adult horses (≥2 years of age). No breed or gender predilection. Head tossing or head shaking is an early clinical sign that often precedes vestibular dysfunction. Facial nerve paralysis may precede vestibular signs in some horses.

Physical Examination Findings Vital signs are within normal limits. Peripheral vestibular syndrome characterized by: Head tilt (toward the lesion). Horizontal nystagmus (fast phase away from the lesion). Circling (toward the lesion). Torticollis. Strabismus (ipsilateral, ventrolateral). Head tossing/ear flopping, pain on palpation of the base of the ear, and head shyness are early clinical signs that may precede petrous temporal bone fracture. Facial nerve paralysis (drooping of the ipsilateral ear, eye, and muzzle) with loss of menace and palpebral reflexes. Corneal ulceration resulting from failure to blink (cranial nerve VII dysfunction) and disruption of parasympathetic innervation to the lacrimal gland (reduced tear production). Difficult prehension due to paralysis of the muzzle and pain associated with the fracture. Possible dysphagia due to damage to the glossopharyngeal and vagus nerves if the petrous temporal bone fractures. Complete or partial hearing loss is common on the affected side. In horses with bilateral structural abnormalities, partial hearing loss may be present contralateral to vestibular signs.

Diagnostic Findings Endoscopic Examination of the Upper Airway (Including Guttural Pouches) More sensitive than radiographic examination for detection of early osseous proliferation.

Standing lateral radiographs of the skull and ventrodorsal radiographs of the skull while the patient is under general anesthesia reveal sclerosis of the tympanic bulla and the proximal portion of the stylohyoid bone. Because of minimal displacement of fracture fragments, the actual fracture of the petrous temporal bone may be difﬁcult to identify. Sequential lateral oblique radiographic views of the skull at varying angles may aid in localizing a fracture.

CriticalPo nt This disorder should be the primary diagnostic differential in cases of acuteonset vestibular dysfunction with facial nerve paralysis.

Computed Tomography Computed tomography with the patient under general anesthesia provides excellent visualization of any bony abnormalities. If surgery FIGURE 1

Endoscopic examination of the guttural pouch of a horse with otitis media/interna. Note the bulbous enlargement of the proximal portion of the stylohyoid bone at the base of the petrous temporal bone (circle).

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Vestibular Disease: Temporohyoid Osteoarthropathy is planned, computed tomography should be performed immediately before surgery.

Laboratory Findings Complete blood count and serum chemistry analysis results are typically unremarkable. Neutrophilia may be present in horses with focal meningitis.

Head Trauma Diagnosis is based on radiographic examination of the skull. Identiﬁcation of fracture of the petrous temporal bone without proliferation of the stylohyoid bone is consistent with fracture due to head trauma.

Polyneuritis Equi

Other Significant Diagnostic Findings

CriticalPo nt Head tossing or head shaking is an early clinical sign that often precedes vestibular dysfunction.

Otoscopic examination (using an 8-mm flexible endoscope) should be performed with the patient under sedation to identify rupture of the tympanic membrane. Schirmer’s test confirms reduced tear production. Cerebrospinal fluid (CSF) should be analyzed in horses with signs of depression to detect focal meningitis at the fracture site. Aggressive antimicrobial therapy is warranted in horses with abnormal CSF cytology characterized by neutrophilic inflammation (normal: five cells/μL) and an increased protein level (normal: 80 mg/dL) consistent with bacterial infection. Ampicillin and chloramphenicol or rifampin are appropriate choices for initial therapy, pending results of bacterial culture and sensitivity.

Clinical signs of cauda equina dysfunction (urinary and fecal incontinence, perineal hypalgesia) are evident during neurologic examination.

Head Shaking Syndrome Before fracture, horses with temporohyoid arthropathy may demonstrate head tossing as their only clinical sign, particularly under tack. This syndrome can be ruled out based on abnormal ﬁndings on upper airway endoscopy.

Lightning Strike Acute unilateral vestibular disease (with or without facial nerve paralysis) due to degeneration and necrosis of the sensory hair cells of the inner ear. Diagnosis is based on history and exclusion of other differentials.

Summary of Diagnostic Criteria Differential Diagnosis Equine Protozoal Myelitis Concurrent brainstem dysfunction may be detected during neurologic examination. Diagnosis is based on immunoblot analysis of CSF to detect antibodies against Sarcocystis neurona. In addition, an indirect ﬂuorescent antibody test (IFAT) may be conducted on whole blood or CSF to detect antibodies to S. neurona. The IFAT maintains validity for CSF samples in the presence of blood contamination up to 100,000 erythrocytes/μL.

Endoscopic examination of the guttural pouch reveals bony proliferation of the proximal stylohyoid bone. Radiographic evaluation may not be necessary if endoscopic examination of the guttural pouch is diagnostic. If radiographic or endoscopic abnormalities are not apparent, clinical signs may result from inner ear effusion (this is rare). Nuclear scintigraphic evaluation of the skull may identify early bony lesions.

Treatment Recommendations Initial Treatment

Checkpoints BOX 1

If facial nerve function does not return within 3–4 months, improvement is unlikely. The clinician should not expect proliferation of the stylohyoid bone to resolve after treatment.

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Trimethoprim–sulfamethoxazole (15–30 mg/kg PO q12h for 30 days). Phenylbutazone (2 mg/kg PO q12h for 14 days) or ﬂunixin meglumine (0.5–1.1 mg/ kg PO q12h for 14 days). Corticosteroids (dexamethasone: 0.05–0.10 mg/kg IV q24h) have been used as a potent antiinﬂammatory therapy. Because of the immunosuppressive and systemic adverse effects of dexamethasone, caution should be exercised.

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Vestibular Disease: Temporohyoid Osteoarthropathy Alternative/Optional Treatment Partial Stylohyoid Ostectomy Surgical removal of a 2-cm midshaft segment of the stylohyoid bone dissipates forces generated by the hyoid apparatus during normal lingual and laryngeal movement. Ideally done before onset of neurologic dysfunction to prevent fracture of the petrous temporal bone. When performed in a group of horses after petrous temporal bone fracture (vestibular/ facial nerve paralysis), approximately 40% of the horses improved. Dysphagia and difﬁcult prehension may be observed for 1 week after surgery.

Ceratohyoidectomy Surgical disarticulation of the ceratohyoid bone from the basihyoid bone, followed by disarticulation of the ceratohyoid–stylohyoid joint, is performed on the affected side. Broad-spectrum antimicrobials should be administered for 2 to 4 weeks.

Antiinﬂammatory therapy is recommended for 1 to 2 weeks. It is reported that most horses appear more comfortable and return to eating within 3 to 5 days after surgery.

Supportive Treatment Regular ophthalmic examinations Because of facial nerve paralysis, it is imperative to monitor the horse’s eye for corneal ulceration and to treat it appropriately with antimicrobials (e.g., neomycin–bacitracin–polymyxin). If uveitis is present, additional treatment, including 1% atopic ointment, is warranted. Ophthalmic ointment to treat or prevent corneal ulcers. Ophthalmic preparations with corticosteroids are contraindicated. Monitor the corneal ulcer carefully for signs of change. 1% Atropine ophthalmic ointment (as needed to maintain mydriasis) for horses with

CriticalPo nt This condition can be unilateral or bilateral, so it is important to endoscopically examine both guttural pouches.

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Vestibular Disease: Temporohyoid Osteoarthropathy acute uveitis (e.g., aqueous ﬂare and miosis). Offer soft feeds for 2 to 3 weeks to minimize pain and prevent further displacement of fracture fragments. Check teeth for molar points and ﬂoat carefully, if needed, to avoid oral ulceration secondary to paralysis.

Patient Monitoring

CriticalPo nt Otoscopic examination (using an 8-mm ﬂexible endoscope) should be performed with the patient under sedation to identify rupture of the tympanic membrane and detect contralateral otitis.

Clinical signs are most severe at the time of fracture. Circling, disorientation, and nystagmus resolve within days or weeks due to visual compensation. Romberg’s test (blindfolding and cautious manipulation) should be conducted to differentiate improvement in vestibulocochlear nerve function from central compensation due to visual input. Caution is imperative when blindfolding affected patients, which may fall suddenly due to loss of visual input. A subtle head tilt persists in most cases. Facial nerve paralysis often improves but rarely resolves.

Farm Management Horses should be maintained in a stall with secure footing for the ﬁrst 2 to 3 weeks until visual compensation eliminates disorientation. Soft feeds and/or mashes can help minimize pain and prevent further displacement of fracture fragments. After the initial 2 to 3 weeks of stall rest, horses can be maintained at pasture. They may decompensate for a few seconds when moving from bright to dark conditions because of the loss of visual compensation.

Milestones/Recovery Time Frames 1 to 2 weeks: Dysphagia and difﬁcult prehension improve. 2 to 3 weeks: Nystagmus, circling, and loss of balance improve. 2 to 3 months: Facial nerve paralysis may improve.

Treatment Contraindications Hard feedstuffs (i.e., cracked corn). Ophthalmic preparations with corticosteroids. In a horse with a break in the blood–brain barrier due to a petrous temporal bone fracture, we observed hyperresponsiveness and seizure after administration of enrofloxacin. Enrofloxacin is not labeled for use in humans due to adverse central nervous system effects (including seizure). Caution should be exercised when using enrofloxacin in patients with temporohyoid osteoarthropathy and a break in the blood–brain barrier.

Prognosis Favorable Criteria Resolution of vestibular dysfunction. Few horses regain vestibulocochlear nerve function. The clinician can differentiate complete resolution from visual compensation by blindfolding. Resolution of facial nerve paralysis.

Unfavorable Criteria Clinical signs of secondary meningitis: fever, depression, seizure. Melting corneal ulcer ipsilateral to facial nerve paralysis; may require enucleation.

Recommended Reading Aleman M, Puchalski SM, Williams DC, et al. Brainstem auditory-evoked responses in horses with temporohyoid osteoarthropathy. J Vet Intern Med 2008;22:1196-1202. Bentz BG, Ross MW, Bentz BG. Otitis media/interna in horses. Compend Contin Educ Pract Vet 1997;19:524-534. Blythe LL, Watrous BJ, Shires MH, et al. Prophylactic partial stylohyoidostectomy for horses with osteoarthropathy of the temporohyoid joint. J Equine Vet Sci 1994;14:32-37. Divers TJ, Ducharme NG, de Lahunta N, et al. Temporohyoid osteoarthropathy. Clin Tech Equine Pract 2006;5:17-23. Hassel DM, Schott HC, Tucker RL, Hines MT. Endoscopy of the auditory tube diverticula in four horses with otitis media/interna. JAVMA 1995;207:1081-1084. Mitchell E, Furr MO, McKenzie HC. Antimicrobial therapy for bacterial meningitis. Equine Vet Educ 2007;19(6):316-323. Rush BR. Vestibular disease. In: Reed SM, Bayly WM, eds. Equine Internal Medicine. Philadelphia: WB Saunders; 1998:466-472.

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Abstract Thoughts Highlighting scientiﬁc articles with important information relating to equine diseases

Inﬂammation and Male Infertility: A Break in Immune Privilege Affects “Mojo” Column Editors ❯❯ David J. Hurley, PhD ❯e-mail djhurley@uga.edu ❯❯ James N. Moore, DVM, PhD The University of Georgia

CriticalPo nt Although reproductive biologists and immunologists have “declared” that testicular tissue is immune privileged, there is growing evidence that local inﬂammatory and immune responses to infection and tissue damage occur in the testes as they do in other body tissues.

ABSTR ACT * Cytokines are regulatory proteins involved in haematopoiesis, immune cell development, inflammation and immune responses. Several cytokines have direct effects on testicular cell functions, and a number of these are produced within the testis even in the absence of inflammation or immune activation events. There is compelling evidence that cytokines, in fact, play an important regulatory role in the development and normal function of the testis. Pro-inflammatory cytokines including interleukin-1 and interleukin-6 have direct effects on spermatogenic cell differentiation and testicular steroidogenesis. Stem cell factor and leukaemia inhibitory factor, cytokines normally involved in haematopoiesis, also play a role in spermatogenesis. Anti-inflammatory cytokines of the transforming growth factor-beta family are implicated in testicular development. Consequently, local or systemic up-regulation of cytokine expression during injury, illness or infection may contribute to the disruption of testicular function and fertility that frequently accompanies these conditions. The aim of this review is to provide a very brief summary of the extensive literature dealing with cytokines in testicular biology, and to follow this with some speculation concerning the significance of these molecules in interactions between the immune system and the testis.

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Fertility is a full-time job. Sperm production is a nearly continuous enterprise that requires a very delicate balance of hormones and cellular interactions. Although reproductive biologists and immunologists have “declared” that testicular tissue is immune privileged, there is growing evidence that local inflammatory and immune responses to infection and tissue damage occur in the testes as they do in other body tissues. However, it has been widely observed that grafts to the testes have an extended acceptance period, suggesting that this tissue has a natural level of “immune neutrality.” Clinically, it has been demonstrated that many cases of chronic infertility in humans (and likely in all other mammals) are driven by chronic inflammatory processes that result in the development of antisperm antibody–mediated autoimmunity and permanent infertility. Testicular infections or injuries have reportedly resulted in transient periods of infertility that may last for days or weeks. The interesting balance between active inflammatory/immune responses and the apparent dampening of inflammatory and immune activity in the testes seems to be related to two major modulations of typical immune regulation. The resident macrophages in the testes have weaker-than-normal inflammatory cytokine responses to common inflammatory triggers and produce

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*Reprinted verbatim from Hedger MP, Meinhardt A. Cytokines and the immune-testicular axis. J Reprod Immunol 2003;58(1):1-26; with permission from Elsevier.

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Abstract Thoughts

CriticalPo nt Antiinﬂammatory cytokines (e.g., TGF-β, c-kit receptor, IL-10) are produced in the testes by resident macrophages. These cytokines appear to provide a strong basis for the perceived immune privilege of the testes.

284

higher-than-normal quantities of cytokines that have immune-dampening activities.1 In contrast, monocytes, mast cells, neutrophils, and lymphocytes recruited in the presence of testicular infection or injury produce levels of cytokines, lipid mediators (e.g., prostaglandins), and regulatory peptides at levels comparable to those observed in other areas of the body. The inflammatory products produced by recruited inflammatory cells act in autocrine and paracrine modes to dampen sperm development, reduce androgen production, and increase estrogen production, all of which reduce the maturation rate of sperm and depress fertility during the days and weeks that follow these inflammatory processes. The article by Hedger and Meinhardt provides a clear and relatively complete review of the knowledge base concerning the cross talk between the immune system and testicular function. While this excellent review article primarily covers studies in rodents and is hesitant to extend these fi ndings beyond their strict experimental context, it contains a lot of information that can help explain how bacterial or viral infections, or physical damage to the scrotum and testes, can produce infertile stallions. Further, it indirectly suggests that injuries or infections not directly involving the testes may initiate a cytokine-mediated “endocrine” response that may modulate the function of cells critical to sperm development or may induce enzymes that alter the androgen–estrogen balance in stallions. Some cytokines have a particularly interesting role in modulating male fertility. For example, interleukin (IL)-6, a cytokine that can have proinflammatory or antiinflammatory effects, depending on when it is produced and the other cytokines are expressed, increases aromatase activity in the testes of mice infected with Taenia crassiceps.2 Aromatase converts androgen into estrogen, leading to loss of sperm production and, in this infection model, to feminization of male mice. IL-6 is produced by Sertoli cells during spermatogenesis under the control of follicle-stimulating hormone (FSH), testosterone, and neuropeptides. IL-6 is an important regulator of testosterone production and, at physiologic levels, is a component of spermatogenesis. In an inflammatory situation, the effects of IL-6 and IL-1β lead to a reduction in androgen concentration that interferes with sperm production.

IL-1 has two isoforms—IL-1α and IL-1β. IL-1β, the predominant form, is released during an inflammatory response, whereas IL-1α is primarily restricted to the cells that produce it and regulates many other functions. IL-1α is produced by Sertoli cells and acts on many cells in the cascade, leading to spermatogenesis. IL-1β inhibits the response of Sertoli cells to FSH and stimulates production of transferrin and lactate by Sertoli cells. Inflammatory IL-1β alters the function of P450 enzymes responsible for steroidogenesis from cholesterol in Leydig cells, leading to a reduction in the number of functional sperm. Tumor necrosis factor α (TNF-α) and FasL (expression of this cell death–associated receptor is increased by TNF-α) play a role in the survival of postmeiotic protosperm cells. TNF-α reduces Leydig cell steroidogenesis and alters patterns of apoptosis (programmed cell death) in germ cells. Working together with IL-1β, TNF-α provides a strong inhibitory signal to sperm production. TNF-α also induces the expression of FasL on Sertoli cells, marking them as targets for apoptosis. When the rate of apoptosis of Sertoli cells is excessive, it reduces the efficiency of sperm production. TNF-α also induces interferon γ (IFN-γ) production by T cells in tissue. The combination of IFN-γ and TNF-α leads to a further increase in apoptosis in many different cells within the testes and reduces the number of mature sperm produced. Antiinflammatory cytokines (e.g., transforming growth factor β [TGF-β], c-kit receptor, IL-10) are produced in the testes by resident macrophages. These cytokines appear to provide a strong basis for the perceived immune privilege of the testes. They dampen the inflammatory and immune responses and are produced routinely in the testes during sperm development, both by resident macrophages and by other cells that regulate sperm development. While the concept of immune privilege appears to be true for the testes, it does not mean that testicular damage or infection will not result in an inflammatory or immune response. Considerable evidence shows that inflammatory cells are strongly recruited to infected or damaged testicular tissue in rats and that lymphocytes, monocytes, and dendritic cells are found in variable numbers in human and rodent testes (where they have been studied).1 In addition, in vivo studies in

Compendium Equine: Continuing Education for Veterinarians® | July/August 2009 | CompendiumEquine.com

Abstract Thoughts mice and rats have shown that these recruited cells function much as they do elsewhere in the body. Further, in some experimental models, administration of exogenous cytokines (e.g., IL-1, TNF-α, IFN-γ) has induced changes in steroidogenesis, aromatase activity, and sperm maturation, suggesting that infection at a site remote from the testes that induces a strong systemic inflammatory response may also temporarily alter male fertility. Therefore, when inflammation is involved, the theme for testicular function may be, “There’s a bad moon on the rise.”3 However, if inflammation can be well managed, a stallion could whinny, “Got my mojo working.”4

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References 1. Hedger MP. Macrophages and the immune responsiveness of the testis. J Reprod Immunol 2002;57:19-34. 2. Morales-Montor J, Baig S, Mitchell R, et al. Immunoendocrine interactions during chronic cysticercosis determine male mouse feminization: role of IL-6. J Immunol 2001;167:4527-4533. 3. John Fogerty. Bad moon on the rise. Green River [album]. Fantasy Records: 1969. 4. Preston Foster. Got my mojo working. 1956. Muddy Waters. Baton Records: 1957.

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The product information presented here is provided by the manufacturers and does not reﬂect endorsement by Compendium Equine.

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PRACTICES FOR SALE FLORIDA Only Fort Meade practice with real estate. Will consider associate/buy-in! FL40.

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GEORGIA Only practice in Irwin County with real estate. Great school district! Owner willing to stay on! GA8.

NEW YORK Upstate 100% equine practice: 4,600–sq. ft. state-of-the-art facility; 3,300–sq. ft. home; 11 acres. Will consider leasing real estate. NY4.

TEXAS Only practice in southern Texas town with 5,000–sq. ft. facility on 5 ¾ acres. TX1.

Call for Papers

Other Available Practices: California, Florida, Georgia, New Hampshire, New Jersey. PS Broker, Inc. • 1-800-636-4740 • www.psbroker.com

Index to Advertisers For free information about products advertised in this issue, e-mail the product names to productinfo@CompendiumEquine.com. Company

Product

Page #

Alberts American College of Veterinary Surgeons Bayer HealthCare Animal Health Dandy Products, Inc Equine Oxygen Therapy, LLC Freedom Health, LLC Intervet/Schering-Plough Animal Health

Carbide Blades Veterinary Symposium: The Surgical Summit Legend Padding and Flooring Hyperbaric Treatment Succeed Equine Fecal Blood Test EquiRab We’re for the Horse. We’re for You. Adequan i.m. Compounding Pharmacy Equioxx Dormosedan Platinum Performance Triple Crown Feeds MYLAB Ultrasound, UMS 900, TERAVET T3000 CECenter.com A Guide to Equine Joint Injection and Regional Anesthesia

273 272 245 277 263 Back cover 247 264–265 249 285 252, 253 Inside front cover, 241 251 257 261 250 Inside back cover

Veterinary Technician Veterinary Therapeutics 82nd Annual Conference

281 287 259

Luitpold Pharmaceuticals, Inc Meds for Vets Merial Pﬁzer Animal Health Platinum Performance, Inc Triple Crown Nutrition, Inc Universal Ultrasound Veterinary Learning Systems

Western Veterinary Conference

Are you involved in research? Veterinary Therapeutics: Research in Applied Veterinary Medicine® is a quarterly journal dedicated to rapid publication. We invite the submission of clinical and laboratory research manuscripts in small animal, large animal, and comparative medicine, including pathophysiology, diagnosis, treatment, and prognosis. Prospective, retrospective, and corroborative studies are all welcome. Submitted articles are scheduled to be published 90 to 120 days after acceptance. Contact Cheryl Hobbs, 800-426-9119, ext 52408, or e-mail chobbs@vetlearn.com.

It’s not just therapeutics!

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The Final Diagnosis ❯❯ Bo Brock, DVM, DABVP (Equine), Brock Veterinary Clinic, Lamesa, Texas

Through the Eyes, and Ears, of a Child

few years ago, Dr. Marty Ivey of Ruidoso, New Mexico, called me at about 11:00 PM with some bad news. He had a horse with colic that was probably going to need surgery. Based on the driving time from Ruidoso, I estimated that the horse would arrive at my practice in Lamesa, Texas, at about 3:00 AM. I met the horse carrier at the clinic at the expected time, evaluated the horse, and confirmed Dr. Ivey’s suspicions. I told the carrier that surgery was our only option. “This is a really special horse,” said the road-weary carrier. “I sure hope you can save him.”

I could see a picture of me on Country Music Television, with Toby Keith telling the interviewer, “Yeah, that’s the stupid vet in Lamesa who killed my best horse.”

TO LEARN MORE The Final Diagnosis gives readers a chance to share their wondrous, weird, or legendary cases or anecdotes. E-mail submissions (no more than 1500 words) to jmoore@uga.edu. CompendiumEquine.com

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Over the years, I’ve learned that every horse is a “really special horse” in the eyes of someone. Now, I just agree and go on. Then the carrier followed up with, “This horse belongs to Toby Keith.” I have to admit that I was overwhelmed by mixed emotions: proud that Toby Keith’s horse was brought to my clinic, worried that Toby Keith’s horse was brought to my clinic, and, to be honest, a bit more pressed than usual to do my best during surgery. As I scrubbed in, I could see a picture of me on Country Music Television, with Toby Keith telling the interviewer, “Yeah, that’s the stupid vet in Lamesa who killed my best horse.”

Worse yet, I might become the subject of a new country song about the “redneck vet from West Texas.” My surgical crew performed the surgery just as we had on hundreds of other horses before. It went well, and the patient looked good when we headed to our homes at the crack of dawn. When I arrived home, I gathered the three Brock girls together to tell them the news. They love Toby Keith, have all of his CDs, and know every song by heart. I knew they’d have lots of WOWs and REALLYs for me. While the two oldest girls were clearly excited, my youngest, Kimmi, ﬂoored me by saying, “I knew this was going to happen,” with an “I told you so” look in her eyes as if she had been expecting this for some time. What in the world, I wondered, would elicit this reaction from an 8-year-old child? My wife, Kerri, and I sat there stunned, until Kimmi said, “Yeah, I knew it was going to happen. You’re not supposed to give beer to horses!” For those of you who haven’t heard the Toby Keith song she was referring to, the line is, “Whiskey for my men, beer for my horses.” While I’ve never understood what this line meant, Kimmi ﬁgured it was just a matter of time before Toby’s horse ended up in Lamesa with gut problems. A diagnostic clinician in the making. Fortunately, the horse did well and went home. We never heard a word from Toby, but as far as Kimmi was concerned, I should have let him know that whiskey might be okay for men, but he better keep the beer away from his horses.

Compendium Equine: Continuing Education for Veterinarians® | July/August 2009 | CompendiumEquine.com

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